Patient Summary Record Test Data – Set #2

{| 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
|----
|Ruth Warholde
|05/20/1954<br>23:59:45
|Female
|9836469798
|Medical Record Number
|225 Park Street <br>Morton, <br>Illinois  61550<br>309-354-9385
|----
|----
|}

“Source” for all data for this patient: Jackson Shoals, 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
|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
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|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
|----
|}

{| 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
|----
|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
|----
|539712
|Medication
|nitrofurantoin
|Macrobid
|100 mg
|1 Capsule
|PO
|QD
|09/22/2008
|No Longer Active
|----
|836370
|Medication
|ipratropium bromide monhydrate
|Atrovent inhaler
|18 mcg/puff
|2 puffs
|By oral inhalation
|QID
|08/14/2007
|Active
|----
|884175
|Medication
|clonidine hydrochloride
|Catapres
|0.1 mg
|1 Tablet
|PO
|BID
|05/16/2006
|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
|Nausea, vomiting, rash, dizziness, headache
|03/25/2003
|----
|Drug Allergy
|91939003
|Sulfonamides
|Hives, photosensitivity
|07/26/1999
|----
|}

{| 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
|----
|Imaging
|11539-4
|CT, head
|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease. 
|02/24/2010
|----
|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
|----
|Microbiology
|630-4
|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)
|Negative: No growth
|10/02/2008
|----
|}

{| 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
|66.39
|Bilateral tubal ligation
|Completed
|06/14/1990
|----
|----
!scope="col"|Type
!scope="col"|CPT Code*
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Surgical
|58600
|Bilateral tubal ligation
|----