| 1 | Patient Summary Record Test Data Set #3
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| 2 |
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| 3 | Patient
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| 4 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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| 5 | Lorraine|04/16/1957|Female|967385998|Medical Record Number|1020 Stuart Street
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| 6 | Blevins|20:15:35|Morton,
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| 7 |
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| 8 | Source for all data for this patient: Louis Randolph, MD
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| 9 |
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| 10 | Problem List
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| 11 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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| 12 | Diagnosis|715.35|Right hip osteoarthritis|Resolved|02/12/2010
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| 13 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002
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| 14 |
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| 15 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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| 16 | Disorder|239872002|Right hip osteoarthritis|Resolved|02/12/2010
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| 17 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002
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| 18 |
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| 19 | Medication List
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| 20 | RxNorm
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| 21 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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| 22 | Code
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| 23 | 855320|Medication|warfarin|Coumadin|3 mg|1 Tablet|PO|QD|02/15/2010|Active
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| 24 | 209613|Medication|bisacodyl|Dulcolax|5 mg|1 Tablet|PO|QD|02/15/2010|Active
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| 25 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|05/15/2002|Active
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| 26 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active
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| 27 |
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| 28 | Medication Allergy List
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| 29 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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| 30 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|06/06/1998
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| 31 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994
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| 32 |
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| 33 | Diagnostic Test Results
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| 34 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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| 35 | Subchondral sclerosis,
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| 36 | 37721-8
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| 37 | Imaging|X-ray, 2 views, Right Hip|increased density in|02/12/2010
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| 38 | subchondral bone
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| 39 | No disease is seen in the lung
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| 40 | Imaging|24648-8|Chest X-ray, PA|06/05/2009
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| 41 | fields or pleura
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| 42 | Hemoglobin (male: 14-18 g/dl
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| 43 | Hematology|718-7|11.2 g/dl|06/05/2009
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| 44 | female: 12-16 g/dl)
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| 45 | Hematocrit (male: 40-54%
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| 46 | Hematology|4544-3|34%|06/05/2009
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| 47 | female: 36-48%)
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| 48 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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| 49 | Prothrombin Time/ International Normalized Ratio (PT/INR)
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| 50 | Coagulation|34714-6|3.1|06/05/2009
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| 51 | (2.5 3.5)
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| 52 |
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| 53 | Procedure List
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| 54 | Type|ICD-9 Code|Procedure|Status|Date Performed
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| 55 | Surgical|81.51|Total Hip Replacement, Right|Completed|02/14/2010
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| 56 | Cardiac|37.21|Cardiac catheterization|Completed|05/05/2002
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| 57 |
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| 58 | Type|CPT Code*|Procedure|Status|Date Performed
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| 59 | Surgical|27130|Total Hip Replacement, Right|Completed|02/14/2010
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| 60 | Cardiac|93501|Cardiac catheterization|Completed|05/05/2002
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