Patient Summary Record Test Data – Set #3

{| 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
|----
|Jane Andrews
|05/12/1955 09:30:15
|Female
|9639275266
|Medical Record Number
|355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364
|----
|}

“Source” for all data for this patient: Robert James, 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
|486
|Pneumonia
|Resolved
|01/22/2010
|----
|Diagnosis
|496.0
|Chronic Obstructive Pulmonary Disease
|Chronic
|10/10/1999
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|233604007
|Pneumonia
|Resolved
|01/22/2010
|----
|Disorder
|13645005
|Chronic Obstructive Lung Disease
|Chronic
|10/10/1999
|----
|}

{| 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
|----
|308460
|Medication
|azithromycin
|Azithromycin
|250 mg
|1 Tablet
|PO
|QD
|01/22/2010
|No Longer Active
|----
|836370
|Medication
|ipratropium bromide monhydrate
|Atrovent Inhaler
|18 mcg/puff
|2 Puffs
|Inhaled
|QID
|10/10/1999
|Active
|----
|630208
|Medication
|albuterol sulfate
|Albuterol Inhaler
|2.5 mg/3ml
|2 Puffs
|Inhaled
|Q 4 PRN
|10/10/1999
|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
|91936005
|Penicillin
|Rash and anaphylaxis
|06/10/2009
|----
|Drug Allergy
|91939003
|Sulfonamides
|Hives, photosensitivity
|04/25/1988
|----
|}

{| 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
|----
|42272-5
|Imaging
|Chest X-ray, PA & Lateral
|Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement
|02/15/2010
|----
|Hematology
|718-7
|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
|16 g/dl
|12/22/2009
|----
|Hematology
|4544-3
|Hematocrit (male: 40-54%<br>female: 36-48%)
| 45%
|12/22/2009
|----
|Cardiology
|34534-8
|Electrocardiogram
|Normal Sinus Rhythm
|12/22/2009
|----