Difference between revisions of "NIST Ambulatory Test Patient 3"
From VistApedia
DaveMishler (talk | contribs) (Initial data entry) |
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| − | !colspan="5"|Medication Allergy List | + | !colspan="5"|Medication [[Allergy~|Allergy]] List |
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!scope="col"|Date Recorded | !scope="col"|Date Recorded | ||
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| − | |Drug Allergy | + | |Drug [[Allergy~|Allergy]] |
|91936005 | |91936005 | ||
|Penicillin | |Penicillin | ||
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|06/10/2009 | |06/10/2009 | ||
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| − | |Drug Allergy | + | |Drug [[Allergy~|Allergy]] |
|91939003 | |91939003 | ||
|Sulfonamides | |Sulfonamides | ||
Revision as of 08:32, 22 February 2012
Patient Summary Record Test Data – Set #3
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Jane Andrews | 05/12/1955 09:30:15 | Female | 9639275266 | Medical Record Number | 355 1st Street Fargo, North Dakota 54102 701-366-8364 |
“Source” for all data for this patient: Robert James, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 486 | Pneumonia | Resolved | 01/22/2010 | |
| Diagnosis | 496.0 | Chronic Obstructive Pulmonary Disease | Chronic | 10/10/1999 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 233604007 | Pneumonia | Resolved | 01/22/2010 | |
| Disorder | 13645005 | Chronic Obstructive Lung Disease | Chronic | 10/10/1999 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 308460 | Medication | azithromycin | Azithromycin | 250 mg | 1 Tablet | PO | QD | 01/22/2010 | No Longer Active |
| 836370 | Medication | ipratropium bromide monhydrate | Atrovent Inhaler | 18 mcg/puff | 2 Puffs | Inhaled | QID | 10/10/1999 | Active |
| 630208 | Medication | albuterol sulfate | Albuterol Inhaler | 2.5 mg/3ml | 2 Puffs | Inhaled | Q 4 PRN | 10/10/1999 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 06/10/2009 |
| Drug Allergy | 91939003 | Sulfonamides | Hives, photosensitivity | 04/25/1988 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| 42272-5 | Imaging | Chest X-ray, PA & Lateral | Hyperinflated lungs with flattened diaphragm and central pulmonary artery enlargement |
02/15/2010 |
| Hematology | 718-7 | Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) |
16 g/dl | 12/22/2009 |
| Hematology | 4544-3 | Hematocrit (male: 40-54% female: 36-48%) |
45% | 12/22/2009 |
| Cardiology | 34534-8 | Electrocardiogram | Normal Sinus Rhythm | 12/22/2009 |
