NIST-Inpatient-test-patient-4: Difference between revisions

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#REDIRECT [[NIST Ambulatory Test Patient 1]]
Patient Summary Record Test Data – Set #4


{| 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
|----
|Paul Jackson
|03/08/1962<br>14:25:50
|Male
|998777349
|Medical Record Number
|754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
|----
|}
“Source” for all data for this patient: Mary Pfiffer, 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
|410.90
|Acute Myocardial Infarction
|Resolved
|07/12/2010
|----
|Finding
|414.01
|Coronary Artery Disease (CAD)
|Chronic
|07/05/2000
|----
|----
!scope="col"|Type
!scope="col"|SNOMED Code*
!scope="col"|Patient Problem
!scope="col"|Status
!scope="col"|Date Diagnosed
|----
|Disorder
|57054005
|Acute Myocardial Infarction
|Resolved
|07/12/2010
|----
|Disorder
|53741008
|Coronary Arteriosclerosis
|Chronic
|07/05/2000
|----
|}
{| 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
|----
|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
|----
|}
{| 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
|91936005
|Penicillin
|Rash and anaphylaxis
|07/12/2010
|----
|Drug Allergy
|294506009
|Ampicillin
|Diarrhea, nausea, vomiting
|03/28/2000
|----
|}
{| 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
|----
|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 <br>enlarged, the hilar and <br>mediastinal vessels are of <br>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
|----
|}
{| border="1"|
!colspan="5"|Procedure List
|----
!scope="col"|Type
!scope="col"|ICD-9 Code
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Cardiac
|00.66
|Percutaneous transluminal coronary angioplasty
|Completed
|07/15/2010
|----
|----
!scope="col"|Type
!scope="col"|CPT Code*
!scope="col"|Procedure
!scope="col"|Status
!scope="col"|Date Performed
|----
|Cardiac
|92982
|Percutaneous transluminal coronary angioplasty
|Completed
|07/15/2010
|----
|}
--[[User:Glilly|Glilly]] 10:57, 22 Nov 2010 (PST)

Revision as of 18:57, 22 November 2010

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)

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