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