| 1 | Patient Summary Record Test Data Set #3
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| 2 |
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| 3 | Patient
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| 4 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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| 5 | Jane Andrews|05/12/1955|Female|9639275266|Medical Record Number|355 1st Street
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| 6 | 09:30:15|Fargo,
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| 7 | North Dakota|54102
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| 8 | 701-366-8364
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| 9 |
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| 10 | Source for all data for this patient: Robert James, MD
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| 11 |
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| 12 | Problem List
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| 13 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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| 14 | Diagnosis|486|Pneumonia|Resolved|01/22/2010
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| 15 | Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|10/10/1999
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| 16 |
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| 17 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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| 18 | Disorder|233604007|Pneumonia|Resolved|01/22/2010
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| 19 | Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|10/10/1999
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| 20 |
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| 21 | Medication List
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| 22 | RxNorm
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| 23 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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| 24 | Code
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| 25 | 308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|01/22/2010|No Longer
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| 26 |
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| 27 | RxNorm
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| 28 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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| 29 | Code
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| 30 | 836370|Medication|ipratropium|Atrovent|18|2 Puffs|Inhaled|QID|10/10/1999|Active
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| 31 | bromide|Inhaler|mcg/puff
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| 32 | monhydrate
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| 33 | 630208|Medication|Albuterol|2.5|2 Puffs|Inhaled|Q 4 PRN|10/10/1999|Active
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| 34 | albuterol sulfate
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| 35 | Inhaler|mg/3ml
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| 36 |
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| 37 | Medication Allergy List
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| 38 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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| 39 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009
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| 40 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988
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| 41 |
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| 42 | Diagnostic Test Results
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| 43 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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| 44 | Hyperinflated lungs with
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| 45 | 42272-5|flattened diaphragm and
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| 46 | Imaging|Chest X-ray, PA & Lateral|02/15/2010
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| 47 | central pulmonary artery
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| 48 | enlargement
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| 49 | Hemoglobin (male: 14-18 g/dl
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| 50 | Hematology|718-7|16 g/dl|12/22/2009
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| 51 | female: 12-16 g/dl)
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| 52 | Hematocrit (male: 40-54%
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| 53 | Hematology|4544-3|45%|12/22/2009
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| 54 | female: 36-48%)
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| 55 | Cardiology|34534-8|Electrocardiogram|Normal Sinus Rhythm|12/22/2009
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