NIST-Inpatient-test-patient-5

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Revision as of 18:11, 21 November 2010 by Glilly (talk | contribs) (NIST Inpatient Test Patient 5)
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Patient Summary Record Test Data – Set #5

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Christine Taylor 09/22/1965 16:48:25 Female 9787478034 Medical Record Number 754 Angel Street Marshalltown Iowa 50158 641-544-9988

“Source” for all data for this patient: Kathryn Thomson, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 540.0 Acute Appendicitis Resolved 01/09/2010
Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 03/30/2009
Symptom 401.9 Hypertension, Essential Chronic 02/25/2008
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 74400008 Appendicitis Resolved 01/09/2010
Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
Disorder 44054006 Diabetes Mellitus, Type 2 Active 03/30/2009
Disorder 59621000 Essential Hypertension Chronic 02/25/2008
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 03/30/2009 Active
209834 Medication docusate Colace 100 mg 1 Capsule PO BID 03/30/2009 Active
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 02/25/2008 Active
628958 Medication potassium chloride Klor-Con 10 mEq 1 Tablet PO BID 02/25/2008 Active
884175 Medication clonidine hydrochloride Catapres 0.1 mg 1 Tablet PO BID 02/25/2008 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 293620004 Indomethacin Rash, dizziness, headache 06/05/2008
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 05/25/1997
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 08/25/1989
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Chemistry 14771-0 Fasting Blood Glucose (70–100 mg/dl) 126 mg/dl 07/15/2010
Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 07/15/2010
Chemistry 14927-8 Triglycerides (<150 mg/dl) 178 mg/dl 07/15/2010
Imaging 42272-5 Chest X-ray, PA & Lateral The heart outline is normal and the hilar and mediastinal vessels are of normal appearance 02/25/2008
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Surgical 47.09 Emergency Appendectomy Completed 01/09/2010
Type CPT Code* Procedure Status Date Performed
Surgical 44950 Emergency Appendectomy Completed 01/09/2010

--Glilly 10:11, 21 Nov 2010 (PST)