| 1 | Patient Summary Record Test Data Set #5
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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 | Christine Taylor 09/22/1965 Female 9787478034 Medical Record Number 754 Angel Street
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| 6 | 16:48:25 Marshalltown
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| 7 | Iowa 50158
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| 8 | 641-544-9988
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| 9 |
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| 10 | Source for all data for this patient: Kathryn Thomson, MD
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| 11 |
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| 12 | Problem List
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| 13 | Type ICD-9 Code Patient Problem Status Date Diagnosed
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| 14 | Diagnosis 540.0 Acute Appendicitis Resolved 01/09/2010
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| 15 | Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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| 16 | Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 03/30/2009
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| 17 | Symptom 401.9 Hypertension, Essential Chronic 02/25/2008
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| 18 |
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| 19 | Type SNOMED Code* Patient Problem Status Date Diagnosed
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| 20 | Disorder 74400008 Appendicitis Resolved 01/09/2010
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| 21 | Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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| 22 | Disorder 44054006 Diabetes Mellitus, Type 2 Active 03/30/2009
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| 23 | Disorder 59621000 Essential Hypertension Chronic 02/25/2008
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| 24 |
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| 25 | Medication List
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| 26 | RxNorm
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| 27 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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| 28 | Code
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| 29 | 309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
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| 30 | 205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 03/30/2009 Active
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| 31 | 209834 Medication docusate Colace 100 mg 1 Capsule PO BID 03/30/2009 Active
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| 32 | 200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 02/25/2008 Active
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| 33 | potassium
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| 34 | 628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 02/25/2008 Active
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| 35 | chloride
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| 36 | RxNorm
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| 37 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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| 38 | Code
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| 39 | clonidine
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| 40 | 884175 Medication Catapres 0.1 mg 1 Tablet PO BID 02/25/2008 Active
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| 41 | hydrochloride
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| 42 |
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| 43 | Medication Allergy List
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| 44 | Type SNOMED Code Medication/Agent Reaction Date Recorded
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| 45 | Drug Allergy 293620004 Indomethacin Rash, dizziness, headache 06/05/2008
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| 46 | Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 05/25/1997
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| 47 | Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 08/25/1989
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| 48 |
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| 49 | Diagnostic Test Results
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| 50 | Type LOINC Code Test (Normal Range) Result Date Performed
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| 51 | Chemistry 14771-0 Fasting Blood Glucose (70100 mg/dl) 126 mg/dl 07/15/2010
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| 52 |
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| 53 | Chemistry 2823-3 Potassium (3.55.3 mg/dl) 4.3 mg/dl 07/15/2010
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| 54 | Chemistry 14927-8 Triglycerides (<150 mg/dl) 178 mg/dl 07/15/2010
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| 55 |
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| 56 | The heart outline is normal
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| 57 | 42272-5 and the hilar and
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| 58 | Imaging Chest X-ray, PA & Lateral mediastinal vessels are of 02/25/2008
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| 59 |
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| 60 | normal appearance
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| 61 |
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| 62 | Procedure List
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| 63 | Type ICD-9 Code Procedure Status Date Performed
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| 64 | Surgical 47.09 Emergency Appendectomy Completed 01/09/2010
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| 65 |
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| 66 | Type CPT Code* Procedure Status Date Performed
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| 67 | Surgical 44950 Emergency Appendectomy Completed 01/09/2010
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| 68 |
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| 69 |
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