Difference between revisions of "NIST-Inpatient-test-patient-2"

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#REDIRECT [[NIST-Inpatient-test-patient-3]]
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Patient Summary Record Test Data – Set #2
  
 +
{| border="1"|
 +
!colspan="6"|Patient
 +
|----
 +
!scope="col"|Name
 +
!scope="col"|Date/Time of Birth
 +
!scope="col"|Gender
 +
!scope="col"|Identification Number
 +
!scope="col"|Identification Number Type
 +
!scope="col"|Address/Phone
 +
|----
 +
|Ruth Warholde
 +
|05/20/1954<br>23:59:45
 +
|Female
 +
|9836469798
 +
|Medical Record Number
 +
|225 Park Street <br>Morton, <br>Illinois  61550<br>309-354-9385
 +
|----
 +
|----
 +
|}
 +
 +
“Source” for all data for this patient: Jackson Shoals, MD
 +
 +
{| border="1"|
 +
!colspan="6"|Problem List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Diagnosis
 +
|780.2
 +
|Syncope and collapse, vasovagal attack
 +
|Active
 +
|02/15/2010
 +
|----
 +
|Diagnosis
 +
|434.91
 +
|Cerebrovascular Accident (Stroke)
 +
|Resolved
 +
|07/09/2009
 +
|----
 +
|Diagnosis
 +
|599.0
 +
|Urinary tract infection
 +
|Recurrent
 +
|09/22/2008
 +
|----
 +
|Diagnosis
 +
|496.0
 +
|Chronic Obstructive Pulmonary Disease
 +
|Chronic
 +
|08/12/2007
 +
|----
 +
|Symptom
 +
|401.9
 +
|Hypertension, essential
 +
|Chronic
 +
|05/16/2006
 +
|----
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code*
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Disorder
 +
|398665005
 +
|Vasovagal syncope
 +
|Active
 +
|02/15/2010
 +
|----
 +
|Disorder
 +
|230690007
 +
|Cerebrovascular Accident (Stroke)
 +
|Resolved
 +
|07/09/2009
 +
|----
 +
|Disorder
 +
|197927001
 +
|Recurrent urinary tract infection
 +
|Recurrent
 +
|09/22/2008
 +
|----
 +
|Disorder
 +
|13645005
 +
|Chronic Obstructive Lung Disease
 +
|Chronic
 +
|08/12/2007
 +
|----
 +
|Disorder
 +
|59621000
 +
|Essential Hypertension
 +
|Chronic
 +
|05/16/2006
 +
|----
 +
|}
 +
 +
{| border="1"|
 +
!colspan="10"|Medication List
 +
|----
 +
!scope="col"|RxNorm Code
 +
!scope="col"|Product
 +
!scope="col"|Generic Name
 +
!scope="col"|Brand Name
 +
!scope="col"|Strength
 +
!scope="col"|Dose
 +
!scope="col"|Route
 +
!scope="col"|Frequency
 +
!scope="col"|Date Started
 +
!scope="col"|Status
 +
|----
 +
|209834
 +
|Medication
 +
|docusate
 +
|Colace
 +
|100 mg
 +
|1 Capsule
 +
|PO
 +
|BID
 +
|02/16/2010
 +
|Active
 +
|----
 +
|205326
 +
|Medication
 +
|lisinopril
 +
|Zestril
 +
|30 mg
 +
|1 Tablet
 +
|PO
 +
|QD
 +
|07/15/2009
 +
|Active
 +
|----
 +
|309362
 +
|Medication
 +
|clopidogrel
 +
|Plavix
 +
|75 mg
 +
|1 Tablet
 +
|PO
 +
|QD
 +
|07/15/2009
 +
|Active
 +
|----
 +
|197361
 +
|Medication
 +
|amlodipine
 +
|Norvasc
 +
|5 mg
 +
|1 Tablet
 +
|PO
 +
|QD
 +
|07/15/2009
 +
|Active
 +
|----
 +
|539712
 +
|Medication
 +
|nitrofurantoin
 +
|Macrobid
 +
|100 mg
 +
|1 Capsule
 +
|PO
 +
|QD
 +
|09/22/2008
 +
|No Longer Active
 +
|----
 +
|836370
 +
|Medication
 +
|ipratropium bromide monhydrate
 +
|Atrovent inhaler
 +
|18 mcg/puff
 +
|2 puffs
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|By oral inhalation
 +
|QID
 +
|08/14/2007
 +
|Active
 +
|----
 +
|884175
 +
|Medication
 +
|clonidine hydrochloride
 +
|Catapres
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|0.1 mg
 +
|1 Tablet
 +
|PO
 +
|BID
 +
|05/16/2006
 +
|Active
 +
|----
 +
|}
 +
 +
{| border="1"|
 +
!colspan="5"|Medication Allergy List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code
 +
!scope="col"|Medication/Agent
 +
!scope="col"|Reaction
 +
!scope="col"|Date Recorded
 +
|----
 +
|Drug Allergy
 +
|293620004
 +
|Indomethacin
 +
|Nausea, vomiting, rash, dizziness, headache
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|03/25/2003
 +
|----
 +
|Drug Allergy
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|91939003
 +
|Sulfonamides
 +
|Hives, photosensitivity
 +
|07/26/1999
 +
|----
 +
|}
 +
 +
{| border="1"|
 +
!colspan="5"|Diagnostic Test Results
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|LOINC Code
 +
!scope="col"|Test (Normal Range)
 +
!scope="col"|Result
 +
!scope="col"|Date Performed
 +
|----
 +
|Imaging
 +
|11539-4
 +
|CT, head
 +
|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease.
 +
|02/24/2010
 +
|----
 +
|Hematology
 +
|718-7
 +
|Hemoglobin (male: 14-18 g/dl  female: 12-16 g/dl)
 +
|13 g/dl
 +
|02/17/2010
 +
|----
 +
|Hematology
 +
|4544-3
 +
|Hematocrit (male: 40-54%  female: 36-48%)
 +
|38%
 +
|02/17/2010
 +
|----
 +
|Chemistry
 +
|2951-2
 +
|Sodium (135–146 mg/dl)
 +
|136 mg/dl
 +
|02/17/2010
 +
|----
 +
|Chemistry
 +
|2823-3
 +
|Potassium (3.5–5.3 mg/dl)
 +
|3.9 mg/dl
 +
|02/17/2010
 +
|----
 +
|Imaging
 +
|34534-8
 +
|Electrocardiogram
 +
|Normal Sinus Rhythm
 +
|02/15/2010
 +
|----
 +
|Microbiology
 +
|630-4
 +
|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)
 +
|Negative: No growth
 +
|10/02/2008
 +
|----
 +
|}
 +
 +
{| border="1"|
 +
!colspan="5"|Procedure List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
 +
|Surgical
 +
|66.39
 +
|Bilateral tubal ligation
 +
|Completed
 +
|06/14/1990
 +
|----
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|CPT Code*
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
 +
|Surgical
 +
|58600
 +
|Bilateral tubal ligation
 +
|----
 +
|}
 +
--[[User:Glilly|Glilly]] 12:49, 22 Nov 2010 (PST)

Revision as of 20:49, 22 November 2010

Patient Summary Record Test Data – Set #2

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Ruth Warholde 05/20/1954
23:59:45 		Female 9836469798 Medical Record Number 225 Park Street
Morton,
Illinois 61550
309-354-9385

“Source” for all data for this patient: Jackson Shoals, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 780.2 Syncope and collapse, vasovagal attack Active 02/15/2010
Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
Diagnosis 599.0 Urinary tract infection Recurrent 09/22/2008
Diagnosis 496.0 Chronic Obstructive Pulmonary Disease Chronic 08/12/2007
Symptom 401.9 Hypertension, essential Chronic 05/16/2006
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 398665005 Vasovagal syncope Active 02/15/2010
Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
Disorder 197927001 Recurrent urinary tract infection Recurrent 09/22/2008
Disorder 13645005 Chronic Obstructive Lung Disease Chronic 08/12/2007
Disorder 59621000 Essential Hypertension Chronic 05/16/2006
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
209834 Medication docusate Colace 100 mg 1 Capsule PO BID 02/16/2010 Active
205326 Medication lisinopril Zestril 30 mg 1 Tablet PO QD 07/15/2009 Active
309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/15/2009 Active
539712 Medication nitrofurantoin Macrobid 100 mg 1 Capsule PO QD 09/22/2008 No Longer Active
836370 Medication ipratropium bromide monhydrate Atrovent inhaler 18 mcg/puff 2 puffs By oral inhalation QID 08/14/2007 Active
884175 Medication clonidine hydrochloride Catapres 0.1 mg 1 Tablet PO BID 05/16/2006 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 293620004 Indomethacin Nausea, vomiting, rash, dizziness, headache 03/25/2003
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 07/26/1999
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Imaging 11539-4 CT, head Small high right occipital lobe
contusion. No evidence of
extra-axial blood. Significant
sinus disease. 		02/24/2010
Hematology 718-7 Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) 13 g/dl 02/17/2010
Hematology 4544-3 Hematocrit (male: 40-54% female: 36-48%) 38% 02/17/2010
Chemistry 2951-2 Sodium (135–146 mg/dl) 136 mg/dl 02/17/2010
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 3.9 mg/dl 02/17/2010
Imaging 34534-8 Electrocardiogram Normal Sinus Rhythm 02/15/2010
Microbiology 630-4 Urine culture, routine
(Negative: No growth Positive: >10,000 CFU/ml) 		Negative: No growth 10/02/2008
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Surgical 66.39 Bilateral tubal ligation Completed 06/14/1990
Type CPT Code* Procedure Status Date Performed
Surgical 58600 Bilateral tubal ligation

--Glilly 12:49, 22 Nov 2010 (PST)

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