Patient Summary Record Test Data – Set #5

{| border="1"|
!colspan="6"|Patient
|----
!scope="col"|Name
!scope="col"|Date/Time of Birth
!scope="col"|Gender
!scope="col"|Identification Number
!scope="col"|Identification Number Type
!scope="col"|Address/Phone
|----
|Christine Taylor
|09/22/1965 16:48:25
|Female
|9787478034
|Medical Record Number
|754 Angel Street Marshalltown Iowa 50158 641-544-9988
|----
|}

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

{| border="1"|
!colspan="6"|Problem List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|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
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|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
|----
|}

{| border="1"|
!colspan="10"|Medication List
|----
!scope="col"|RxNorm Code
!scope="col"|Product
!scope="col"|Generic Name
!scope="col"|Brand Name
!scope="col"|Strength
!scope="col"|Dose
!scope="col"|Route
!scope="col"|Frequency
!scope="col"|Date Started
!scope="col"|Status
|----
|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
|----
|628958
|Medication
|potassium chloride
|Klor-Con
|10 mEq
|1 Tablet
|PO
|BID
|02/25/2008
|Active
|----
|884175
|Medication
|clonidine hydrochloride
|Catapres
|0.1 mg
|1 Tablet
|PO
|BID
|02/25/2008
|Active
|----
|}

{| border="1"|
!colspan="5"|Medication Allergy List
|----
!scope="col"|Type
!scope="col"|SNOMED Code
!scope="col"|Medication/Agent
!scope="col"|Reaction
!scope="col"|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
|----
|}

{| border="1"|
!colspan="5"|Diagnostic Test Results
|----
!scope="col"|Type
!scope="col"|LOINC Code
!scope="col"|Test (Normal Range)
!scope="col"|Result
!scope="col"|Date Performed
|----
|Chemistry
|14771-0
|Fasting Blood Glucose (70–100 mg/dl)
|126 mg/dl
|07/15/2010
|----
|Chemistry
|2823-3
|Potassium (3.5–5.3 mg/dl)
|4.3 mg/dl
|07/15/2010
|----
|Chemistry
|14927-8
|Triglycerides (<150 mg/dl)
|178 mg/dl
|07/15/2010
|----
|Imaging
|42272-5
|Chest X-ray, PA & Lateral
|The heart outline is normal<br> and the hilar and mediastinal<br> vessels are of normal appearance
|02/25/2008
|----
|}

{| border="1"|
!colspan="5"|Procedure List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Surgical
|47.09
|Emergency Appendectomy
|Completed
|01/09/2010
|----
|----
!scope="col"|Type
!scope="col"|CPT Code*
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Surgical
|44950
|Emergency Appendectomy
|Completed
|01/09/2010
|----
|}