| 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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