54 lines
2.1 KiB
Plaintext
54 lines
2.1 KiB
Plaintext
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Patient Summary Record Test Data <20> Set #4
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Patient
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Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
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Paul Jackson|03/08/1962|Male|998777349|Medical Record Number|754 Samuel Street,
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14:25:50|Blanchard,
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Oklahoma 73010
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405-228-9292
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<EFBFBD>Source<EFBFBD> for all data for this patient: Mary Pfiffer, MD
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Problem List
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Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
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Diagnosis|410.90|Acute Myocardial Infarction|Resolved|07/12/2010
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Finding|414.01|Coronary Artery Disease (CAD)|Chronic|07/05/2000
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Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
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Disorder|57054005|Acute Myocardial Infarction|Resolved|07/12/2010
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Disorder|53741008|Coronary Arteriosclerosis|Chronic|07/05/2000
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Medication List
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RxNorm
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|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
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Code
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198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|07/15/2010|Active
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309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/05/2000|Active
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197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/05/2000|Active
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Medication Allergy List
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Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
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Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|07/12/2010
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Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/28/2000
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Diagnostic Test Results
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Type|LOINC Code|Test (Normal Range)|Result|Date Performed
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Chemistry|14647-2|Total cholesterol (<200 mg/dl)|220 mg/dl|07/15/2010
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Chemistry|14927-8|Triglycerides (<150 mg/dl)|165 mg/dl|07/15/2010
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The heart outline is slightly
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enlarged, the hilar and
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Imaging|42272-5|Chest X-ray, PA & Lateral|07/15/2010
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mediastinal vessels are of
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normal appearance
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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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Hematology|4544-3|Hematocrit (male: 40-54%|female: 36-48%)|44%|2/18/2010
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Procedure List
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Type|ICD-9 Code|Procedure|Status|Date Performed
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Cardiac|00.66|Percutaneous transluminal coronary|Completed|07/15/2010
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angioplasty
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Type|CPT Code*|Procedure|Status|Date Performed
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Cardiac|92982|Percutaneous transluminal coronary|Completed|07/15/2010
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angioplasty
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