| 1 | Patient Summary Record Test Data Set #2
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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 | Ruth Warholde|05/20/1954<br>23:59:45|Female|9836469798|Medical Record Number|225 Park Street <br>Morton, <br>Illinois 61550<br>309-354-9385
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| 6 | |
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| 7 |
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| 8 | Source for all data for this patient: Jackson Shoals, 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|780.2|Syncope and collapse, vasovagal attack|Active|02/15/2010
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| 13 | Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
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| 14 | Diagnosis|599.0|Urinary tract infection|Recurrent|09/22/2008
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| 15 | Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|08/12/2007
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| 16 | Symptom|401.9|Hypertension, essential|Chronic|05/16/2006
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| 17 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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| 18 | Disorder|398665005|Vasovagal syncope|Active|02/15/2010
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| 19 | Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
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| 20 | Disorder|197927001|Recurrent urinary tract infection|Recurrent|09/22/2008
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| 21 | Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|08/12/2007
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| 22 | Disorder|59621000|Essential Hypertension|Chronic|05/16/2006
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| 23 |
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| 24 | Medication List
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| 25 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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| 26 | 209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|02/16/2010|Active
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| 27 | 205326|Medication|lisinopril|Zestril|30 mg|1 Tablet|PO|QD|07/15/2009|Active
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| 28 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active
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| 29 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active
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| 30 | 539712|Medication|nitrofurantoin|Macrobid|100 mg|1 Capsule|PO|QD|09/22/2008|No Longer Active
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| 31 | 836370|Medication|ipratropium bromide monhydrate|Atrovent inhaler|18 mcg/puff|2 puffs|By oral inhalation|QID|08/14/2007|Active
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| 32 | 884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|05/16/2006|Active
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| 33 |
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| 34 | Medication Allergy List
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| 35 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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| 36 | Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003
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| 37 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|07/26/1999
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| 38 |
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| 39 | Diagnostic Test Results
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| 40 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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| 41 | Imaging|11539-4|CT, head|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease. |02/24/2010
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| 42 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|13 g/dl|02/17/2010
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| 43 | Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|38%|02/17/2010
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| 44 | Chemistry|2951-2|Sodium (135146 mg/dl)|136 mg/dl|02/17/2010
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| 45 | Chemistry|2823-3|Potassium (3.55.3 mg/dl)|3.9 mg/dl|02/17/2010
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| 46 | Imaging|34534-8|Electrocardiogram|Normal Sinus Rhythm|02/15/2010
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| 47 | Microbiology|630-4|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)|Negative: No growth|10/02/2008
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| 48 |
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| 49 | Procedure List
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| 50 | Type|ICD-9 Code|Procedure|Status|Date Performed
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| 51 | Surgical|66.39|Bilateral tubal ligation|Completed|06/14/1990
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| 52 | Type|CPT Code*|Procedure|Status|Date Performed
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| 53 | Surgical|58600|Bilateral tubal ligation|
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