Patient Summary Record Test Data  Set #5 

Patient 
      Name           Date/Time of Birth        Gender          Identification Number             Identification Number Type                Address/Phone 
Christine Taylor      09/22/1965              Female         9787478034                        Medical Record Number                   754 Angel Street 
                     16:48:25                                                                                                         Marshalltown 
                                                                                                                                      Iowa  50158 
                                                                                                                                      641-544-9988 

Source for all data for this patient: Kathryn Thomson, MD 

Problem List 
        Type                 ICD-9 Code                                Patient Problem                                Status               Date Diagnosed 
Diagnosis                540.0                      Acute Appendicitis                                           Resolved              01/09/2010 
Diagnosis                434.91                     Cerebrovascular Accident (Stroke)                            Resolved              07/09/2009 
Diagnosis                250.02                     Diabetes Mellitus, Type 2                                   Active                 03/30/2009 
Symptom                  401.9                      Hypertension, Essential                                      Chronic               02/25/2008 

        Type               SNOMED Code*                                Patient Problem                                Status               Date Diagnosed 
Disorder                 74400008                   Appendicitis                                                 Resolved              01/09/2010 
Disorder                 230690007                  Cerebrovascular Accident (Stroke)                            Resolved              07/09/2009 
Disorder                 44054006                   Diabetes Mellitus, Type 2                                    Active                03/30/2009 
Disorder                 59621000                   Essential Hypertension                                       Chronic               02/25/2008 

Medication List 
  RxNorm 
                   Product         Generic Name         Brand Name         Strength        Dose        Route       Frequency        Date Started        Status 
    Code 
309362           Medication        clopidogrel          Plavix              75 mg        1 Tablet       PO        QD                07/15/2009        Active 
205875           Medication        glyburide            Diabeta             2.5 mg      1 Tablet        PO        Q AM             03/30/2009         Active 
209834           Medication        docusate             Colace              100 mg      1 Capsule       PO        BID               03/30/2009        Active 
200801           Medication        furosemide           Lasix               20 mg        1 Tablet       PO        BID               02/25/2008        Active 
                                  potassium 
628958           Medication                            Klor-Con             10 mEq       1 Tablet       PO         BID              02/25/2008        Active 
                                  chloride 
RxNorm 
                   Product         Generic Name         Brand Name        Strength        Dose        Route      Frequency        Date Started        Status 
    Code 
                                                       clonidine 
884175           Medication        Catapres                               0.1 mg        1 Tablet       PO        BID               02/25/2008       Active 
                                                       hydrochloride 

Medication Allergy List 
          Type                      SNOMED Code                        Medication/Agent                        Reaction                   Date Recorded 
Drug Allergy                 293620004                            Indomethacin                       Rash, dizziness, headache         06/05/2008 
Drug Allergy                 294506009                            Ampicillin                         Diarrhea, nausea, vomiting        05/25/1997 
Drug Allergy                 91939003                             Sulfonamides                       Hives, photosensitivity           08/25/1989 

Diagnostic Test Results 
          Type                   LOINC Code                     Test (Normal Range)                             Result                    Date Performed 
Chemistry                    14771-0                   Fasting Blood Glucose (70100 mg/dl)         126 mg/dl                         07/15/2010 

Chemistry                    2823-3                    Potassium (3.55.3 mg/dl)                    4.3 mg/dl                         07/15/2010 
Chemistry                    14927-8                   Triglycerides (<150 mg/dl)                   178 mg/dl                         07/15/2010 

                                                                                                    The heart outline is normal 
                            42272-5                                                                 and the hilar and 
Imaging                                                Chest X-ray, PA & Lateral                    mediastinal vessels are of        02/25/2008 

                                                                                                    normal appearance 

Procedure List 
        Type                  ICD-9 Code                              Procedure                                   Status                  Date Performed 
Surgical                  47.09                      Emergency Appendectomy                             Completed                      01/09/2010 

         Type                  CPT Code*                              Procedure                                   Status                  Date Performed 
Surgical                   44950                     Emergency Appendectomy                             Completed                      01/09/2010 

                                                                               