2.1 KiB
2.1 KiB
| 1 | Patient Summary Record Test Data – Set #4 |
|---|---|
| 2 | Patient |
| 3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
| 4 | 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 |
| 5 | “Source” for all data for this patient: Mary Pfiffer, MD |
| 6 | Problem List |
| 7 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 8 | Diagnosis|410.90|Acute Myocardial Infarction|Resolved|07/12/2010 |
| 9 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|07/05/2000 |
| 10 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 11 | Disorder|57054005|Acute Myocardial Infarction|Resolved|07/12/2010 |
| 12 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|07/05/2000 |
| 13 | Medication List |
| 14 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 15 | 198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|07/15/2010|Active |
| 16 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/05/2000|Active |
| 17 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/05/2000|Active |
| 18 | Medication Allergy List |
| 19 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 20 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|07/12/2010 |
| 21 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/28/2000 |
| 22 | Diagnostic Test Results |
| 23 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 24 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|220 mg/dl|07/15/2010 |
| 25 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|165 mg/dl|07/15/2010 |
| 26 | 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 |
| 27 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|12.8 g/dl|2/18/2010 |
| 28 | Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|44%|2/18/2010 |
| 29 | Procedure List |
| 30 | Type|ICD-9 Code|Procedure|Status|Date Performed |
| 31 | Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010 |
| 32 | Type|CPT Code*|Procedure|Status|Date Performed |
| 33 | Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010 |