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