2.1 KiB
2.1 KiB
1 | Patient Summary Record Test Data – Set #4 |
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2 | Patient |
3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
4 | Paul Jackson|03/08/1962|Male|998777349|Medical Record Number|754 Samuel Street, |
5 | 14:25:50|Blanchard, |
6 | Oklahoma 73010 |
7 | 405-228-9292 |
8 | “Source” for all data for this patient: Mary Pfiffer, MD |
9 | Problem List |
10 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
11 | Diagnosis|410.90|Acute Myocardial Infarction|Resolved|07/12/2010 |
12 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|07/05/2000 |
13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
14 | Disorder|57054005|Acute Myocardial Infarction|Resolved|07/12/2010 |
15 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|07/05/2000 |
16 | Medication List |
17 | RxNorm |
18 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
19 | Code |
20 | 198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|07/15/2010|Active |
21 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/05/2000|Active |
22 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/05/2000|Active |
23 | Medication Allergy List |
24 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
25 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|07/12/2010 |
26 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/28/2000 |
27 | Diagnostic Test Results |
28 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
29 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|220 mg/dl|07/15/2010 |
30 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|165 mg/dl|07/15/2010 |
31 | The heart outline is slightly |
32 | enlarged, the hilar and |
33 | Imaging|42272-5|Chest X-ray, PA & Lateral|07/15/2010 |
34 | mediastinal vessels are of |
35 | normal appearance |
36 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl|female: 12-16 g/dl)|12.8 g/dl|2/18/2010 |
37 | Hematology|4544-3|Hematocrit (male: 40-54%|female: 36-48%)|44%|2/18/2010 |
38 | Procedure List |
39 | Type|ICD-9 Code|Procedure|Status|Date Performed |
40 | Cardiac|00.66|Percutaneous transluminal coronary|Completed|07/15/2010 |
41 | angioplasty |
42 | Type|CPT Code*|Procedure|Status|Date Performed |
43 | Cardiac|92982|Percutaneous transluminal coronary|Completed|07/15/2010 |
44 | angioplasty |