| Rev | Line | |
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| [1021] | 1 | Clinical Summaries Test Data Set #3 Office Visit #2 for Barbara Simpson
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| 2 |
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| 3 | Problem List
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| 4 | Type ICD-9 Code Patient Problem Status Date Diagnosed
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| 5 | Diagnosis 496.0 Chronic Obstructive Pulmonary Disease Chronic 02/10/2010
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| 6 |
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| 7 | Type SNOMED Code* Patient Problem Status Date Diagnosed
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| 8 | Disorder 13645005 Chronic Obstructive Lung Disease Chronic 02/10/2010
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| 9 |
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| 10 | Medication List
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| 11 | RxNorm
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| 12 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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| 13 | Code
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| 14 | ipratropium
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| 15 | Atrovent 18 Inhale
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| 16 | 836370 Medication bromide 2 Puffs QID 02/10/2010 Active
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| 17 | Inhaler mcg/puff d
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| 18 | monhydrate
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| 19 | Albuterol 2.5 Inhale Q 4 hours as
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| 20 | 630208 Medication albuterol sulfate 2 Puffs 02/10/2010 Active
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| 21 | Inhaler mg/3ml d needed
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| 22 |
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| 23 | Medication Allergy List
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| 24 | Type SNOMED Code Medication/Agent Reaction Date Recorded
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| 25 | Drug Allergy 91936005 Penicillin Rash and anaphylaxis 06/10/2009
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| 26 | Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 04/25/1988
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| 27 |
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| 28 | Diagnostic Test Results
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| 29 | Type LOINC Code Test (Normal Range) Result Date Performed
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| 30 | Hyperinflated lungs with
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| 31 | 42272-5 flattened diaphragm and
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| 32 | Imaging Chest X-ray, PA & Lateral 02/10/2010
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| 33 | central pulmonary artery
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| 34 | enlargement
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| 35 | Hemoglobin (male: 14-18 g/dl
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| 36 | Hematology 718-7 16 g/dl 02/10/2010
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| 37 | female: 12-16 g/dl)
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| 38 | Type LOINC Code Test (Normal Range) Result Date Performed
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| 39 | Hematocrit (male: 40-54%
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| 40 | Hematology 4544-3 45% 02/10/2010
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| 41 | female: 36-48%)
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