Difference between revisions of "NIST-Inpatient-test-patient-4"

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#REDIRECT [[NIST Ambulatory Test Patient 1]]
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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
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|03/08/1962<br>14:25:50
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|Male
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|998777349
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|Medical Record Number
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|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
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|Acute Myocardial Infarction
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|Resolved
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|07/12/2010
 +
|----
 +
|Finding
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|414.01
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|Coronary Artery Disease (CAD)
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|Chronic
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|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
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|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
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|Nitroglycerin
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|400 mcg
 +
|1 Tablet
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|SL
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|As needed
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|07/15/2010
 +
|Active
 +
|----
 +
|309362
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|Medication
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|clopidogrel
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|Plavix
 +
|75 mg
 +
|1 Tablet
 +
|PO
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|QD
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|07/05/2000
 +
|Active
 +
|----
 +
|197361
 +
|Medication
 +
|amlodipine
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|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
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|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)
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|220 mg/dl
 +
|07/15/2010
 +
|----
 +
|Chemistry
 +
|14927-8
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|Triglycerides (<150 mg/dl)
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|165 mg/dl
 +
|07/15/2010
 +
|----
 +
|Imaging
 +
|42272-5
 +
|Chest X-ray, PA & Lateral
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|The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance
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|07/15/2010
 +
|----
 +
|Hematology
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|718-7
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|Hemoglobin (male: 14-18 g/dl
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|female: 12-16 g/dl)
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|12.8 g/dl
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|2/18/2010
 +
|----
 +
|Hematology
 +
|4544-3
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|Hematocrit (male: 40-54%
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|female: 36-48%)
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|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
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|Percutaneous transluminal coronary angioplasty
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|Completed
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|07/15/2010
 +
|----
 +
|----
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!scope="col"|Type
 +
!scope="col"|CPT Code*
 +
!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
 +
|----
 +
|Cardiac
 +
|92982
 +
|Percutaneous transluminal coronary angioplasty
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|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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