NIST-Inpatient-test-patient-4

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

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