| 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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