Patient Summary Record Test Data  Set #3 

Patient 
     Name           Date/Time of Birth         Gender         Identification Number            Identification Number Type                Address/Phone 
Jane Andrews        05/12/1955               Female          9639275266                       Medical Record Number                  355 1st Street 
                   09:30:15                                                                                                         Fargo, 
                                                                                                                                    North Dakota  54102 
                                                                                                                                    701-366-8364 

Source for all data for this patient: Robert James, MD 

Problem List 
        Type                 ICD-9 Code                               Patient Problem                                Status              Date Diagnosed 
Diagnosis                486                       Pneumonia                                                    Resolved              01/22/2010 
Diagnosis                496.0                     Chronic Obstructive Pulmonary Disease                        Chronic               10/10/1999 

        Type              SNOMED Code*                                Patient Problem                                Status              Date Diagnosed 
Disorder                 233604007                 Pneumonia                                                    Resolved              01/22/2010 
Disorder                 13645005                  Chronic Obstructive Lung Disease                             Chronic               10/10/1999 

Medication List 
  RxNorm 
                   Product         Generic Name         Brand Name        Strength        Dose         Route      Frequency       Date Started        Status 
    Code 
308460           Medication        azithromycin         Azithromycin      250 mg        1 Tablet       PO          QD              01/22/2010       No Longer 
                                                              
 RxNorm 
                   Product         Generic Name         Brand Name        Strength         Dose         Route      Frequency       Date Started        Status 
    Code 
836370           Medication        ipratropium         Atrovent           18            2 Puffs        Inhaled     QID              10/10/1999       Active 
                                  bromide              Inhaler            mcg/puff 
                                  monhydrate 
630208           Medication                            Albuterol          2.5           2 Puffs        Inhaled     Q 4 PRN          10/10/1999       Active 
                                  albuterol sulfate 
                                                       Inhaler            mg/3ml 

Medication Allergy List 
          Type                       SNOMED Code                        Medication/Agent                       Reaction                    Date Recorded 
Drug Allergy                 91936005                            Penicillin                           Rash and anaphylaxis              06/10/2009 
Drug Allergy                 91939003                             Sulfonamides                        Hives, photosensitivity           04/25/1988 

Diagnostic Test Results 
          Type                        LOINC Code                      Test (Normal Range)                        Result                    Date Performed 
                                                                                                     Hyperinflated lungs with 
                            42272-5                                                                  flattened diaphragm and 
Imaging                                                          Chest X-ray, PA & Lateral                                             02/15/2010 
                                                                                                     central pulmonary artery 
                                                                                                     enlargement 
                                                                 Hemoglobin (male: 14-18 g/dl 
Hematology                   718-7                                                                   16 g/dl                            12/22/2009 
                                                                 female: 12-16 g/dl) 
                                                                 Hematocrit (male: 40-54% 
Hematology                   4544-3                                                                  45%                                12/22/2009 
                                                                 female: 36-48%) 
Cardiology                   34534-8                              Electrocardiogram                   Normal Sinus Rhythm              12/22/2009 