Clinical Summaries Test Data – Set #2  Office Visit #1 for Robert Flint 

Patient 
        Name              Date/Time of Birth         Gender         Identification Number       Identification Number Type              Address/Phone 
Robert Flint             04/18/1983               Male             9813624798                  Medical Record Number               747 Market Street, 
                         20:18:04                                                                                                  Morton, Illinois  61550 
                                                                                                                                   309-365-8298 

“Source” for all data for this patient: Carl Roberts, MD 

Problem List 
        Type                 ICD-9 Code                              Patient Problem                                Status              Date Diagnosed 
Diagnosis              493.00                     Asthma, unspecified                                         Active                07/19/2009 

        Type              SNOMED Code*                               Patient Problem                                Status              Date Diagnosed 
Disorder                195967001                 Asthma                                                      Active                07/19/2009 

Medication List 
  RxNorm 
                   Product        Generic Name         Brand Name         Strength       Dose        Route       Frequency       Date Started        Status 
    Code 
                                                      Alupent 
                                  metaproterenol 
206833          Medication                            Inhalation         15 mg/ml     2 Puffs       Inhaled    Q4h               07/19/2009       Active 
                                  sulfate 
                                                      Aerosol 

Medication Allergy List 
          Type                      SNOMED Code                        Medication/Agent                       Reaction                   Date Recorded 
Drug Allergy                91936005                             Penicillin                         Rash and anaphylaxis             08/10/2008 
                                                                                                    Nausea, vomiting, rash, 
Drug Allergy                293620004                            Indomethacin                                                        03/25/2003 
                                                                                                    dizziness, headache 

Diagnostic Test Results 
        Type                  LOINC Code                      Test (Normal Range)                               Result                   Date Performed 
Imaging                  24648-8                   Chest X-ray, PA                 Increased bronchial wall markings, patchy infiltrates   07/19/2009