54 lines
5.2 KiB
Plaintext
54 lines
5.2 KiB
Plaintext
Patient Summary Record Test Data – 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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“Source” 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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