207 lines
3.3 KiB
Plaintext
207 lines
3.3 KiB
Plaintext
Patient Summary Record Test Data – Set #4
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{| border="1"|
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!colspan="6"|Patient
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|----
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Paul Jackson
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|03/08/1962<br>14:25:50
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|Male
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|998777349
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|Medical Record Number
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|754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
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|----
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|}
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“Source” for all data for this patient: Mary Pfiffer, MD
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{| border="1"|
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!colspan="6"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Diagnosis
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|410.90
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|Acute Myocardial Infarction
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|Resolved
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|07/12/2010
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|----
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|Finding
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|414.01
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|Coronary Artery Disease (CAD)
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|Chronic
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|07/05/2000
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|57054005
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|Acute Myocardial Infarction
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|Resolved
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|07/12/2010
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|----
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|Disorder
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|53741008
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|Coronary Arteriosclerosis
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|Chronic
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|07/05/2000
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|----
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|}
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{| border="1"|
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!colspan="10"|Medication List
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|198039
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|Medication
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|nitroglycerin
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|Nitroglycerin
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|400 mcg
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|1 Tablet
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|SL
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|As needed
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|07/15/2010
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|Active
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|309362
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|Medication
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|clopidogrel
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|Plavix
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|75 mg
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|1 Tablet
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|PO
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|QD
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|07/05/2000
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|Active
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|197361
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|Medication
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|amlodipine
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|Norvasc
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|5 mg
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|1 Tablet
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|PO
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|QD
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|07/05/2000
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|Active
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|----
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|}
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{| border="1"|
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!colspan="5"|Medication Allergy List
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!scope="col"|Type
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!scope="col"|SNOMED Code
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!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|91936005
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|Penicillin
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|Rash and anaphylaxis
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|07/12/2010
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|----
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|Drug Allergy
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|294506009
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|Ampicillin
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|Diarrhea, nausea, vomiting
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|03/28/2000
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|----
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|}
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{| border="1"|
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!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
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!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
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|----
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|Chemistry
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|14647-2
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|Total cholesterol (<200 mg/dl)
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|220 mg/dl
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|07/15/2010
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|----
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|Chemistry
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|14927-8
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|Triglycerides (<150 mg/dl)
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|165 mg/dl
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|07/15/2010
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|----
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|Imaging
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|42272-5
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|Chest X-ray, PA & Lateral
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|The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance
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|07/15/2010
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|Hematology
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|718-7
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|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)
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|12.8 g/dl
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|2/18/2010
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|----
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|Hematology
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|4544-3
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|Hematocrit (male: 40-54% female: 36-48%)
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|44%
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|2/18/2010
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|}
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{| border="1"|
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!colspan="5"|Procedure List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Cardiac
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|00.66
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|Percutaneous transluminal coronary angioplasty
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|Completed
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|07/15/2010
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|----
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|----
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!scope="col"|Type
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!scope="col"|CPT Code*
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Cardiac
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|92982
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|Percutaneous transluminal coronary angioplasty
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|Completed
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|07/15/2010
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|----
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