| 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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