NIST-Inpatient-test-patient-4

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Patient Summary Record Test Data – Set #4

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Paul Jackson 03/08/1962
14:25:50
Male 998777349 Medical Record Number 754 Samuel Street,
Blanchard,
Oklahoma 73010
405-228-9292

“Source” for all data for this patient: Mary Pfiffer, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 410.90 Acute Myocardial Infarction Resolved 07/12/2010
Finding 414.01 Coronary Artery Disease (CAD) Chronic 07/05/2000
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 57054005 Acute Myocardial Infarction Resolved 07/12/2010
Disorder 53741008 Coronary Arteriosclerosis Chronic 07/05/2000
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
198039 Medication nitroglycerin Nitroglycerin 400 mcg 1 Tablet SL As needed 07/15/2010 Active
309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/05/2000 Active
197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/05/2000 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 91936005 Penicillin Rash and anaphylaxis 07/12/2010
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/28/2000
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Chemistry 14647-2 Total cholesterol (<200 mg/dl) 220 mg/dl 07/15/2010
Chemistry 14927-8 Triglycerides (<150 mg/dl) 165 mg/dl 07/15/2010
Imaging 42272-5 Chest X-ray, PA & Lateral The heart outline is slightly
enlarged, the hilar and
mediastinal vessels are of
normal appearance
07/15/2010
Hematology 718-7 Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) 12.8 g/dl 2/18/2010
Hematology 4544-3 Hematocrit (male: 40-54% female: 36-48%) 44% 2/18/2010
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Cardiac 00.66 Percutaneous transluminal coronary angioplasty Completed 07/15/2010
Type CPT Code* Procedure Status Date Performed
Cardiac 92982 Percutaneous transluminal coronary angioplasty Completed 07/15/2010

CSV Format

--Glilly 10:57, 22 Nov 2010 (PST)