Patient Summary Record Test Data – Set #3 

Patient 
     Name            Date/Time of Birth         Gender           Identification Number             Identification Number Type                 Address/Phone 
Lorraine            04/16/1957                 Female          967385998                         Medical Record Number                    1020 Stuart Street 
Blevins             20:15:35                                                                                                             Morton, 
                                   
“Source” for all data for this patient: Louis Randolph, MD 

Problem List 
        Type                  ICD-9 Code                                Patient Problem                                  Status               Date Diagnosed 
Diagnosis                 715.35                     Right hip osteoarthritis                                       Resolved               02/12/2010 
Finding                   414.01                     Coronary Artery Disease (CAD)                                  Chronic                05/05/2002 

        Type               SNOMED Code*                                 Patient Problem                                  Status               Date Diagnosed 
Disorder                 239872002                  Right hip osteoarthritis                                       Resolved               02/12/2010 
Disorder                  53741008                   Coronary Arteriosclerosis                                      Chronic                05/05/2002 

Medication List 
  RxNorm 
                    Product         Generic Name          Brand Name         Strength        Dose          Route      Frequency        Date Started        Status 
    Code 
855320            Medication        warfarin              Coumadin           3 mg          1 Tablet       PO           QD               02/15/2010        Active 
209613            Medication        bisacodyl             Dulcolax           5 mg          1 Tablet       PO           QD              02/15/2010         Active 
309362            Medication        clopidogrel           Plavix             75 mg         1 Tablet       PO           QD               05/15/2002        Active 
197361            Medication        amlodipine            Norvasc             5 mg         1 Tablet        PO          QD               07/15/2009        Active 

Medication Allergy List 
          Type                        SNOMED Code                         Medication/Agent                         Reaction                    Date Recorded 
Drug Allergy                  91939003                              Sulfonamides                         Hives, photosensitivity            06/06/1998 
Drug Allergy                  294506009                             Ampicillin                           Diarrhea, nausea, vomiting         04/25/1994 

Diagnostic Test Results 
      Type             LOINC Code                           Test (Normal Range)                                          Result                   Date Performed 
                                                                                                           Subchondral sclerosis, 
                     37721-8 
Imaging                                  X-ray, 2 views, Right Hip                                         increased density in                  02/12/2010 
                                                                                                           subchondral bone 
                                                                                                           No disease is seen in the lung 
Imaging              24648-8             Chest X-ray, PA                                                                                         06/05/2009 
                                                                                                           fields or pleura 
                                         Hemoglobin (male: 14-18 g/dl 
Hematology           718-7                                                                                 11.2 g/dl                             06/05/2009 
                                         female: 12-16 g/dl) 
                                         Hematocrit (male: 40-54% 
Hematology           4544-3                                                                                34%                                   06/05/2009 
                                         female: 36-48%) 
 Type            LOINC Code                            Test (Normal Range)                                         Result                   Date Performed 
                                         Prothrombin Time/ International Normalized Ratio (PT/INR) 
Coagulation          34714-6                                                                              3.1                                   06/05/2009 
                                         (2.5 – 3.5) 

Procedure List 
         Type                  ICD-9 Code                               Procedure                                    Status                   Date Performed 
Surgical                   81.51                      Total Hip Replacement, Right                         Completed                       02/14/2010 
Cardiac                    37.21                      Cardiac catheterization                              Completed                       05/05/2002 

         Type                   CPT Code*                               Procedure                                    Status                   Date Performed 
Surgical                   27130                      Total Hip Replacement, Right                         Completed                       02/14/2010 
Cardiac                    93501                      Cardiac catheterization                              Completed                       05/05/2002