Difference between revisions of "NIST Ambulatory Test Patient 1"
From VistApedia
m (Added glossary link to Allergy~) |
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{| border="1"| | {| border="1"| | ||
| − | !colspan="5"|Medication Allergy List | + | !colspan="5"|Medication [[Allergy~|Allergy]] List |
|---- | |---- | ||
!scope="col"|Type | !scope="col"|Type | ||
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!scope="col"|Date Recorded | !scope="col"|Date Recorded | ||
|---- | |---- | ||
| − | |Drug Allergy | + | |Drug [[Allergy~|Allergy]] |
|293597001 | |293597001 | ||
|Codeine | |Codeine | ||
| Line 165: | Line 165: | ||
|06/27/1996 | |06/27/1996 | ||
|---- | |---- | ||
| − | |Drug Allergy | + | |Drug [[Allergy~|Allergy]] |
|294506009 | |294506009 | ||
|Ampicillin | |Ampicillin | ||
Revision as of 07:04, 22 February 2012
* indicates alternative standard code per certification criteria
Patient Summary Record Test Data Set #1
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| John D. Smith | 07/04/1960 10:15:02 | Male | 999999999 | Medical Record Number | 355 Maple Street Williamsport, Pennsylvania 17701 570-837-8364 |
Source for all data for this patient: John Fitzgerald, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 250.02 | Diabetes Mellitus, Type 2 | Active | 09/16/2009 | |
| Condition | 272.4 | Hyperlipidemia | Active | 05/05/2002 | |
| Finding | 414.01 | Coronary Artery Disease (CAD) | Chronic | 05/05/2002 | |
| Symptom | 401.9 | Hypertension, Essential | Active | 05/05/2002 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 44054006 | Diabetes Mellitus, Type 2 | Active | 09/16/2009 | |
| Disorder | 55822004 | Hyperlipidemia | Active | 05/05/2002 | |
| Disorder | 53741008 | Coronary Arteriosclerosis | Chronic | 05/05/2002 | |
| Disorder | 59621000 | Essential Hypertension | Active | 05/05/2002 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 205875 | Medication | glyburide | Diabeta | 2.5 mg | 1 Tablet | PO | Q AM | 09/16/2009 | Active |
| 617314 | Medication | atorvastatin calcium | Lipitor | 10 mg | 1 Tablet | PO | Q Day | 05/05/2002 | Active |
| 200801 | Medication | furosemide | Lasix | 20 mg | 1 Tablet | PO | BID | 05/05/2002 | Active |
| 628958 | Medication | potassium chloride | Klor-Con | 10 mEq | 1 Tablet | PO | BID | 05/05/2002 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 293597001 | Codeine | Hives | 06/27/1996 |
| Drug Allergy | 294506009 | Ampicillin | Diarrhea, nausea, vomiting | 03/15/1994 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Chemistry | 14771-0 | Fasting Blood Glucose (70100 mg/dl) | 178 mg/dl | 09/16/2009 |
| Chemistry | 14682-9 | Creatinine (0.51.4 mg/dl) | 1.0 mg/dl | 09/16/2009 |
| Chemistry | 14937-7 | BUN (730 mg/dl) | 18 mg/dl | 09/16/2009 |
| Chemistry | 2951-2 | Sodium (135146 mg/dl) | 141 mg/dl | 09/16/2009 |
| Chemistry | 2823-3 | Potassium (3.55.3 mg/dl) | 4.3 mg/dl | 09/16/2009 |
| Chemistry | 14647-2 | Total cholesterol (<200 mg/dl) | 162 mg/dl | 09/16/2009 |
| Chemistry | 14646-4 | HDL cholesterol (?40 mg/dl) | 43 mg/dl | 09/16/2009 |
| Chemistry | 2089-1 | LDL cholesterol (<100 mg/dl) | 84 mg/dl | 09/16/2009 |
| Chemistry | 14927-8 | Triglycerides (<150 mg/dl) | 177 mg/dl | 09/16/2009 |
| Imaging | 24648-8 | Chest X-ray, PA | No disease is seen in the lung fields or pleura |
09/16/2009 |
--Glilly 23:27, 21 Nov 2010 (PST)
