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 (135–146 mg/dl) 136 mg/dl 02/17/2010 Chemistry 2823-3 Potassium (3.5–5.3 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