NIST-Inpatient-test-patient-2

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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539712 Medication nitrofurantoin Macrobid 100 mg 1 Capsule PO QD 09/22/2008 No Longer Active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

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