Patient Summary Record Test Data  Set #2 

Patient 
      Name            Date/Time of Birth         Gender          Identification Number              Identification Number Type                  Address/Phone 
Ruth Warholde          05/20/1954              Female           9836469798                         Medical Record Number                    225 Park Street 
                      23:59:45                                                                                                             Morton, 
                                                                          
Source for all data for this patient: Jackson Shoals, MD 

Problem List 
        Type                  ICD-9 Code                                Patient Problem                                  Status                Date Diagnosed 
Diagnosis                 780.2                      Syncope and collapse, vasovagal attack                         Active                 02/15/2010 
Diagnosis                 434.91                     Cerebrovascular Accident (Stroke)                              Resolved               07/09/2009 
Diagnosis                 599.0                      Urinary tract infection                                        Recurrent              09/22/2008 
Diagnosis                 496.0                      Chronic Obstructive Pulmonary Disease                          Chronic                08/12/2007 
Symptom                   401.9                      Hypertension, essential                                        Chronic                05/16/2006 

        Type               SNOMED Code*                                 Patient Problem                                  Status                Date Diagnosed 
Disorder                  398665005                  Vasovagal syncope                                              Active                 02/15/2010 
Disorder                  230690007                  Cerebrovascular Accident (Stroke)                              Resolved               07/09/2009 
Disorder                  197927001                  Recurrent urinary tract infection                              Recurrent              09/22/2008 
Disorder                  13645005                   Chronic Obstructive Lung Disease                               Chronic                08/12/2007 
Disorder                  59621000                   Essential Hypertension                                         Chronic                05/16/2006 

Medication List 
  RxNorm 
                    Product         Generic Name         Brand Name        Strength         Dose          Route       Frequency        Date Started        Status 
    Code 
209834            Medication        docusate              Colace            100 mg       1 Capsule       PO            BID             02/16/2010         Active 
205326            Medication        lisinopril            Zestril           30 mg         1 Tablet       PO            QD              07/15/2009         Active 
309362            Medication        clopidogrel           Plavix            75 mg         1 Tablet       PO            QD               07/15/2009        Active 
197361            Medication        amlodipine            Norvasc          5 mg           1 Tablet       PO            QD               07/15/2009        Active 
                                                                                                                                                         No Longer 
539712            Medication        nitrofurantoin        Macrobid         100 mg         1 Capsule      PO            QD               09/22/2008 
                                                                                                                                                         Active 
                                   ipratropium 
                                                        Atrovent           18                           By oral 
836370            Medication       bromide                                               2 puffs                      QID               08/14/2007        Active 
                                                         inhaler           mcg/puff                     inhalation 
                                   monhydrate 
                                                         clonidine 
884175            Medication        Catapres                               0.1 mg         1 Tablet       PO            BID              05/16/2006        Active 
                                                         hydrochloride 
Medication Allergy List 
          Type                        SNOMED Code                         Medication/Agent                         Reaction                    Date Recorded 
                                                                                                        Nausea, vomiting, rash, 
Drug Allergy                  293620004                             Indomethacin                                                           03/25/2003 
                                                                                                        dizziness, headache 
Drug Allergy                  91939003                              Sulfonamides                         Hives, photosensitivity            07/26/1999 

Diagnostic Test Results 
      Type            LOINC Code                            Test (Normal Range)                                          Result                   Date Performed 
                                                                                                           Small high right occipital lobe 
                                                                                                           contusion. No evidence of 
Imaging               11539-4             CT, head                                                                                               02/24/2010 
                                                                                                           extra-axial blood. Significant 
                                                                                                           sinus disease. 
Hematology            718-7              Hemoglobin (male: 14-18 g/dl           female: 12-16 g/dl)        13 g/dl                                02/17/2010 
Hematology            4544-3             Hematocrit  (male: 40-54%           female: 36-48%)               38%                                    02/17/2010 
Chemistry             2951-2             Sodium (135146 mg/dl)                                             136 mg/dl                            02/17/2010 
Chemistry             2823-3             Potassium (3.55.3 mg/dl)                                          3.9 mg/dl                            02/17/2010 
Imaging               34534-8             Electrocardiogram                                                Normal Sinus Rhythm                   02/15/2010 
                                         Urine culture, routine 
Microbiology          630-4                                                                                Negative: No growth                    10/02/2008 
                                         (Negative: No growth        Positive: >10,000 CFU/ml) 

Procedure List 
         Type                   ICD-9 Code                               Procedure                                    Status                   Date Performed 
Surgical                   66.39                      Bilateral tubal ligation                              Completed                       06/14/1990 

         Type                    CPT Code*                                 Procedure                                     Status                    Date Performed 
Surgical                    58600                       Bilateral tubal ligation    