Patient Summary Record Test Data – Set #4

{| border="1"|
!colspan="6"|Patient
|----
!scope="col"|Name
!scope="col"|Date/Time of Birth
!scope="col"|Gender
!scope="col"|Identification Number
!scope="col"|Identification Number Type
!scope="col"|Address/Phone
|----
|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
|----
|}

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

{| border="1"|
!colspan="6"|Problem List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Diagnosis
|410.90
|Acute Myocardial Infarction
|Resolved
|07/12/2010
|----
|Finding
|414.01
|Coronary Artery Disease (CAD)
|Chronic
|07/05/2000
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|57054005
|Acute Myocardial Infarction
|Resolved
|07/12/2010
|----
|Disorder
|53741008
|Coronary Arteriosclerosis
|Chronic
|07/05/2000
|----
|}

{| border="1"|
!colspan="10"|Medication List
|----
!scope="col"|RxNorm Code
!scope="col"|Product
!scope="col"|Generic Name
!scope="col"|Brand Name
!scope="col"|Strength
!scope="col"|Dose
!scope="col"|Route
!scope="col"|Frequency
!scope="col"|Date Started
!scope="col"|Status
|----
|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
|----
|}

{| border="1"|
!colspan="5"|Medication Allergy List
|----
!scope="col"|Type
!scope="col"|SNOMED Code
!scope="col"|Medication/Agent
!scope="col"|Reaction
!scope="col"|Date Recorded
|----
|Drug Allergy
|91936005
|Penicillin
|Rash and anaphylaxis
|07/12/2010
|----
|Drug Allergy
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|03/28/2000
|----
|}

{| border="1"|
!colspan="5"|Diagnostic Test Results
|----
!scope="col"|Type
!scope="col"|LOINC Code
!scope="col"|Test (Normal Range)
!scope="col"|Result
!scope="col"|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
|----
|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
|----
|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
|----
|}

{| border="1"|
!colspan="5"|Procedure List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Cardiac
|00.66
|Percutaneous transluminal coronary angioplasty
|Completed
|07/15/2010
|----
|----
!scope="col"|Type
!scope="col"|CPT Code*
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Cardiac
|92982
|Percutaneous transluminal coronary angioplasty
|Completed
|07/15/2010
|----