Difference between revisions of "NIST-Inpatient-test-patient-3"

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Revision as of 08:13, 22 February 2012

Patient Summary Record Test Data – Set #3

Patient
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
Lorraine Blevins 04/16/1957
20:15:35
Female 967385998 Medical Record Number 1020 Stuart Street
Morton,
Illinois 61550
309-374-8938

“Source” for all data for this patient: Louis Randolph, MD

Problem List
Type ICD-9 Code Patient Problem Status Date Diagnosed
Diagnosis 715.35 Right hip osteoarthritis Resolved 02/12/2010
Finding 414.01 Coronary Artery Disease (CAD) Chronic 05/05/2002
Type SNOMED Code* Patient Problem Status Date Diagnosed
Disorder 239872002 Right hip osteoarthritis Resolved 02/12/2010
Disorder 53741008 Coronary Arteriosclerosis Chronic 05/05/2002
Medication List
RxNorm Code Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
855320 Medication warfarin Coumadin 3 mg 1 Tablet PO QD 02/15/2010 Active
209613 Medication bisacodyl Dulcolax 5 mg 1 Tablet PO QD 02/15/2010 Active
309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 05/15/2002 Active
197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/15/2009 Active
Medication Allergy List
Type SNOMED Code Medication/Agent Reaction Date Recorded
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 06/06/1998
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
Diagnostic Test Results
Type LOINC Code Test (Normal Range) Result Date Performed
Imaging 37721-8 X-ray, 2 views, Right Hip Subchondral sclerosis,
increased density in
subchondral bone
02/12/2010
Imaging 24648-8 Chest X-ray, PA No disease is seen in
the lung fields or pleura
06/05/2009
Hematology 718-7 Hemoglobin (male: 14-18 g/dl
female: 12-16 g/dl)
11.2 g/dl 06/05/2009
Hematology 4544-3 Hematocrit (male: 40-54%
female: 36-48%)
34% 06/05/2009
Coagulation 34714-6 Prothrombin Time/ International Normalized Ratio (PT/INR)
(2.5 – 3.5)
3.1 06/05/2009
Procedure List
Type ICD-9 Code Procedure Status Date Performed
Surgical 81.51 Total Hip Replacement, Right Completed 02/14/2010
Cardiac 37.21 Cardiac catheterization Completed 05/05/2002
Type CPT Code* Procedure Status Date Performed
Surgical 27130 Total Hip Replacement, Right Completed 02/14/2010
Cardiac 93501 Cardiac catheterization Completed 05/05/2002

CSV Format

--Glilly 11:35, 22 Nov 2010 (PST)