| 1 | Patient Summary Record Test Data Set #4
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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 | Paul Jackson|03/08/1962|Male|998777349|Medical Record Number|754 Samuel Street,
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| 6 | 14:25:50|Blanchard,
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| 7 | Oklahoma 73010
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| 8 | 405-228-9292
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| 9 |
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| 10 | Source for all data for this patient: Mary Pfiffer, 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|410.90|Acute Myocardial Infarction|Resolved|07/12/2010
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| 15 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|07/05/2000
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| 16 |
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| 17 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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| 18 | Disorder|57054005|Acute Myocardial Infarction|Resolved|07/12/2010
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| 19 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|07/05/2000
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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 | 198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|07/15/2010|Active
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| 26 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/05/2000|Active
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| 27 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/05/2000|Active
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| 28 |
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| 29 | Medication Allergy List
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| 30 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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| 31 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|07/12/2010
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| 32 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/28/2000
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| 33 |
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| 34 | Diagnostic Test Results
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| 35 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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| 36 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|220 mg/dl|07/15/2010
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| 37 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|165 mg/dl|07/15/2010
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| 38 | The heart outline is slightly
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| 39 | enlarged, the hilar and
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| 40 | Imaging|42272-5|Chest X-ray, PA & Lateral|07/15/2010
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| 41 | mediastinal vessels are of
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| 42 | normal appearance
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| 43 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl|female: 12-16 g/dl)|12.8 g/dl|2/18/2010
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| 44 | Hematology|4544-3|Hematocrit (male: 40-54%|female: 36-48%)|44%|2/18/2010
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| 45 |
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| 46 | Procedure List
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| 47 | Type|ICD-9 Code|Procedure|Status|Date Performed
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| 48 | Cardiac|00.66|Percutaneous transluminal coronary|Completed|07/15/2010
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| 49 | angioplasty
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| 50 |
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| 51 | Type|CPT Code*|Procedure|Status|Date Performed
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| 52 | Cardiac|92982|Percutaneous transluminal coronary|Completed|07/15/2010
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| 53 | angioplasty
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