NIST-Inpatient-test-patient-2

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539712	Medication	nitrofurantoin	Macrobid	100 mg	1 Capsule	PO	QD	09/22/2008	No Longer Active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