NIST Ambulatory Test Patient 3

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 09:30:15	Female	9639275266	Medical Record Number	355 1st Street 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 Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
308460	Medication	azithromycin	Azithromycin	250 mg	1 Tablet	PO	QD	01/22/2010	No Longer Active
836370	Medication	ipratropium bromide monhydrate	Atrovent Inhaler	18 mcg/puff	2 Puffs	Inhaled	QID	10/10/1999	Active
630208	Medication	albuterol sulfate	Albuterol Inhaler	2.5 mg/3ml	2 Puffs	Inhaled	Q 4 PRN	10/10/1999	Active

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

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