NIST-Inpatient-test-patient-2
From VistApedia
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539712 | Medication | nitrofurantoin | Macrobid | 100 mg | 1 Capsule | PO | QD | 09/22/2008 | No Longer Active |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 |
--Glilly 12:49, 22 Nov 2010 (PST)