| 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<br>14:25:50|Male|998777349|Medical Record Number|754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
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| 6 |
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| 7 | Source for all data for this patient: Mary Pfiffer, MD
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| 8 |
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| 9 | Problem List
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| 10 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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| 11 | Diagnosis|410.90|Acute Myocardial Infarction|Resolved|07/12/2010
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| 12 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|07/05/2000
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| 13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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| 14 | Disorder|57054005|Acute Myocardial Infarction|Resolved|07/12/2010
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| 15 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|07/05/2000
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| 16 |
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| 17 | Medication List
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| 18 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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| 19 | 198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|07/15/2010|Active
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| 20 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/05/2000|Active
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| 21 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/05/2000|Active
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| 22 |
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| 23 | Medication Allergy List
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| 24 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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| 25 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|07/12/2010
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| 26 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/28/2000
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| 27 |
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| 28 | Diagnostic Test Results
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| 29 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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| 30 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|220 mg/dl|07/15/2010
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| 31 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|165 mg/dl|07/15/2010
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| 32 | Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance |07/15/2010
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| 33 | 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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| 34 | Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|44%|2/18/2010
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| 35 |
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| 36 | Procedure List
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| 37 | Type|ICD-9 Code|Procedure|Status|Date Performed
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| 38 | Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010
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| 39 | Type|CPT Code*|Procedure|Status|Date Performed
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| 40 | Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010
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