Patient Summary Record Test Data  Set #4 

Patient 
     Name            Date/Time of Birth         Gender          Identification Number             Identification Number Type                 Address/Phone 
Paul Jackson        03/08/1962                Male            998777349                          Medical Record Number                   754 Samuel Street, 
                    14:25:50                                                                                                            Blanchard, 
                                                                                                                                        Oklahoma 73010 
                                                                                                                                        405-228-9292 

Source for all data for this patient: Mary Pfiffer, MD 

Problem List 
        Type                  ICD-9 Code                                Patient Problem                                 Status               Date Diagnosed 
Diagnosis               410.90                      Acute Myocardial Infarction                                   Resolved                07/12/2010 
Finding                  414.01                      Coronary Artery Disease (CAD)                                 Chronic                07/05/2000 

        Type               SNOMED Code*                                 Patient Problem                                 Status               Date Diagnosed 
Disorder                 57054005                    Acute Myocardial Infarction                                  Resolved                07/12/2010 
Disorder                 53741008                    Coronary Arteriosclerosis                                     Chronic                07/05/2000 

Medication List 
RxNorm 
                    Product         Generic Name         Brand Name         Strength        Dose         Route      Frequency        Date Started        Status 
    Code 
198039            Medication        nitroglycerin        Nitroglycerin       400 mcg      1 Tablet       SL         As needed         07/15/2010        Active 
309362            Medication        clopidogrel          Plavix              75 mg        1 Tablet       PO         QD                07/05/2000        Active 
197361            Medication        amlodipine           Norvasc             5 mg         1 Tablet       PO         QD                07/05/2000        Active 

Medication Allergy List 
          Type                       SNOMED Code                         Medication/Agent                        Reaction                     Date Recorded 
Drug Allergy                  91936005                             Penicillin                           Rash and anaphylaxis               07/12/2010 
Drug Allergy                  294506009                             Ampicillin                          Diarrhea, nausea, vomiting         03/28/2000 

Diagnostic Test Results 
      Type            LOINC Code                            Test (Normal Range)                                        Result                   Date Performed 
Chemistry             14647-2             Total cholesterol (<200 mg/dl)                                   220 mg/dl                            07/15/2010 
Chemistry             14927-8             Triglycerides (<150 mg/dl)                                       165 mg/dl                            07/15/2010 
                                                                                                          The heart outline is slightly 
                                                                                                          enlarged, the hilar and 
Imaging               42272-5             Chest X-ray, PA & Lateral                                                                             07/15/2010 
                                                                                                          mediastinal vessels are of 
                                                                                                          normal appearance 
Hematology            718-7              Hemoglobin (male: 14-18 g/dl       female: 12-16 g/dl)            12.8 g/dl                            2/18/2010 
Hematology            4544-3             Hematocrit (male: 40-54%       female: 36-48%)                    44%                                   2/18/2010 

Procedure List 
         Type                  ICD-9 Code                               Procedure                                   Status                   Date Performed 
Cardiac                    00.66                      Percutaneous transluminal coronary                  Completed                       07/15/2010 
                                                     angioplasty 

         Type                   CPT Code*                               Procedure                                   Status                   Date Performed 
Cardiac                    92982                      Percutaneous transluminal coronary                  Completed                       07/15/2010 
                                                     angioplasty 
