1 | Patient Summary Record Test Data Set #3
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2 |
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3 | {| border="1"|
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4 | !colspan="6"|Patient
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5 | |----
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6 | !scope="col"|Name
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7 | !scope="col"|Date/Time of Birth
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8 | !scope="col"|Gender
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9 | !scope="col"|Identification Number
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10 | !scope="col"|Identification Number Type
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11 | !scope="col"|Address/Phone
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12 | |----
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13 | |Jane Andrews
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14 | |05/12/1955 09:30:15
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15 | |Female
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16 | |9639275266
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17 | |Medical Record Number
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18 | |355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364
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19 | |----
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20 | |}
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21 |
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22 | Source for all data for this patient: Robert James, MD
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23 |
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24 | {| border="1"|
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25 | !colspan="6"|Problem List
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26 | |----
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27 | !scope="col"|Type
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28 | !scope="col"|ICD-9 Code
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29 | !scope="col"|Patient Problem
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30 | !scope="col"|Status
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31 | !scope="col"|Date Diagnosed
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32 | |----
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33 | |Diagnosis
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34 | |486
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35 | |Pneumonia
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36 | |Resolved
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37 | |01/22/2010
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38 | |----
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39 | |Diagnosis
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40 | |496.0
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41 | |Chronic Obstructive Pulmonary Disease
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42 | |Chronic
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43 | |10/10/1999
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44 | |----
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45 | |----
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46 | !scope="col"|Type
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47 | !scope="col"|SNOMED Code*
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48 | !scope="col"|Patient Problem
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49 | !scope="col"|Status
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50 | !scope="col"|Date Diagnosed
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51 | |----
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52 | |Disorder
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53 | |233604007
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54 | |Pneumonia
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55 | |Resolved
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56 | |01/22/2010
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57 | |----
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58 | |Disorder
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59 | |13645005
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60 | |Chronic Obstructive Lung Disease
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61 | |Chronic
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62 | |10/10/1999
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63 | |----
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64 | |}
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65 |
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66 | {| border="1"|
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67 | !colspan="10"|Medication List
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68 | |----
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69 | !scope="col"|RxNorm Code
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70 | !scope="col"|Product
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71 | !scope="col"|Generic Name
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72 | !scope="col"|Brand Name
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73 | !scope="col"|Strength
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74 | !scope="col"|Dose
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75 | !scope="col"|Route
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76 | !scope="col"|Frequency
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77 | !scope="col"|Date Started
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78 | !scope="col"|Status
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79 | |----
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80 | |308460
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81 | |Medication
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82 | |azithromycin
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83 | |Azithromycin
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84 | |250 mg
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85 | |1 Tablet
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86 | |PO
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87 | |QD
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88 | |01/22/2010
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89 | |No Longer Active
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90 | |----
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91 | |836370
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92 | |Medication
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93 | |ipratropium bromide monhydrate
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94 | |Atrovent Inhaler
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95 | |18 mcg/puff
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96 | |2 Puffs
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97 | |Inhaled
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98 | |QID
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99 | |10/10/1999
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100 | |Active
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101 | |----
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102 | |630208
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103 | |Medication
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104 | |albuterol sulfate
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105 | |Albuterol Inhaler
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106 | |2.5 mg/3ml
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107 | |2 Puffs
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108 | |Inhaled
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109 | |Q 4 PRN
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110 | |10/10/1999
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111 | |Active
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112 | |----
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113 | |}
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114 |
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115 | {| border="1"|
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116 | !colspan="5"|Medication Allergy List
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117 | |----
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118 | !scope="col"|Type
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119 | !scope="col"|SNOMED Code
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120 | !scope="col"|Medication/Agent
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121 | !scope="col"|Reaction
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122 | !scope="col"|Date Recorded
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123 | |----
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124 | |Drug Allergy
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125 | |91936005
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126 | |Penicillin
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127 | |Rash and anaphylaxis
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128 | |06/10/2009
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129 | |----
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130 | |Drug Allergy
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131 | |91939003
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132 | |Sulfonamides
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133 | |Hives, photosensitivity
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134 | |04/25/1988
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135 | |----
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136 | |}
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137 |
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138 | {| border="1"|
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139 | !colspan="5"|Diagnostic Test Results
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140 | |----
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141 | !scope="col"|Type
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142 | !scope="col"|LOINC Code
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143 | !scope="col"|Test (Normal Range)
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144 | !scope="col"|Result
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145 | !scope="col"|Date Performed
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146 | |----
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147 | |42272-5
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148 | |Imaging
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149 | |Chest X-ray, PA & Lateral
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150 | |Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement
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151 | |02/15/2010
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152 | |----
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153 | |Hematology
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154 | |718-7
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155 | |Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
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156 | |16 g/dl
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157 | |12/22/2009
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158 | |----
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159 | |Hematology
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160 | |4544-3
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161 | |Hematocrit (male: 40-54%<br>female: 36-48%)
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162 | | 45%
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163 | |12/22/2009
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164 | |----
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165 | |Cardiology
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166 | |34534-8
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167 | |Electrocardiogram
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168 | |Normal Sinus Rhythm
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169 | |12/22/2009
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170 | |----
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