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

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#REDIRECT [[NIST Inpatient Test Patients:set 5]]
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Patient Summary Record Test Data – Set #3
  
 +
{| border="1"|
 +
!colspan="6"|Patient
 +
|----
 +
!scope="col"|Name
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!scope="col"|Date/Time of Birth
 +
!scope="col"|Gender
 +
!scope="col"|Identification Number
 +
!scope="col"|Identification Number Type
 +
!scope="col"|Address/Phone
 +
|----
 +
|Lorraine Blevins
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|04/16/1957<br>20:15:35
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|Female
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|967385998
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|Medical Record Number
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|1020 Stuart Street<br>Morton, <br>Illinois  61550<br> 309-374-8938
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|----
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|}
 +
 +
“Source” for all data for this patient: Louis Randolph, MD
 +
 +
{| border="1"|
 +
!colspan="6"|Problem List
 +
|----
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!scope="col"|Type
 +
!scope="col"|ICD-9 Code
 +
!scope="col"|Patient Problem
 +
!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Diagnosis
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|715.35
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|Right hip osteoarthritis
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|Resolved
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|02/12/2010
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|----
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|Finding
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|414.01
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|Coronary Artery Disease (CAD)
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|Chronic
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|05/05/2002
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|----
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
 +
!scope="col"|Date Diagnosed
 +
|----
 +
|Disorder
 +
|239872002
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|Right hip osteoarthritis
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|Resolved
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|02/12/2010
 +
|----
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|Disorder
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|53741008
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|Coronary Arteriosclerosis
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|Chronic
 +
|05/05/2002
 +
|----
 +
|}
 +
 +
{| border="1"|
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!colspan="10"|Medication List
 +
|----
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!scope="col"|RxNorm Code
 +
!scope="col"|Product
 +
!scope="col"|Generic Name
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!scope="col"|Brand Name
 +
!scope="col"|Strength
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!scope="col"|Dose
 +
!scope="col"|Route
 +
!scope="col"|Frequency
 +
!scope="col"|Date Started
 +
!scope="col"|Status
 +
|----
 +
|855320
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|Medication
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|warfarin
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|Coumadin
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|3 mg
 +
|1 Tablet
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|PO
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|QD
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|02/15/2010
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|Active
 +
|----
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|209613
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|Medication
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|bisacodyl
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|Dulcolax
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|5 mg
 +
|1 Tablet
 +
|PO
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|QD
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|02/15/2010
 +
|Active
 +
|----
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|309362
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|Medication
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|clopidogrel
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|Plavix
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|75 mg
 +
|1 Tablet
 +
|PO
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|QD
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|05/15/2002
 +
|Active
 +
|----
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|197361
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|Medication
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|amlodipine
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|Norvasc
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|5 mg
 +
|1 Tablet
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|PO
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|QD
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|07/15/2009
 +
|Active
 +
|----
 +
|}
 +
 +
{| border="1"|
 +
!colspan="5"|Medication Allergy List
 +
|----
 +
!scope="col"|Type
 +
!scope="col"|SNOMED Code
 +
!scope="col"|Medication/Agent
 +
!scope="col"|Reaction
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!scope="col"|Date Recorded
 +
|----
 +
|Drug Allergy
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|91939003
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|Sulfonamides
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|Hives, photosensitivity
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|06/06/1998
 +
|----
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|Drug Allergy
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|294506009
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|Ampicillin
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|Diarrhea, nausea, vomiting
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|04/25/1994
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|----
 +
|}
 +
 +
{| border="1"|
 +
!colspan="5"|Diagnostic Test Results
 +
|----
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!scope="col"|Type
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!scope="col"|LOINC Code
 +
!scope="col"|Test (Normal Range)
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!scope="col"|Result
 +
!scope="col"|Date Performed
 +
|----
 +
|Imaging
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|37721-8
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|X-ray, 2 views, Right Hip
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|Subchondral sclerosis,<br> increased density in<br>subchondral bone
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|02/12/2010
 +
|----
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|Imaging
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|24648-8
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|Chest X-ray, PA
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|No disease is seen in<br> the lung fields or pleura
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|06/05/2009
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|----
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|Hematology
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|718-7
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|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
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|11.2 g/dl
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|06/05/2009
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|----
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|Hematology
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|4544-3
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|Hematocrit (male: 40-54% <br>female: 36-48%)
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|34%
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|06/05/2009
 +
|----
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|Coagulation
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|34714-6
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|Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 – 3.5)
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|3.1
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|06/05/2009
 +
|----
 +
|}
 +
 +
{| border="1"|
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!colspan="5"|Procedure List
 +
|----
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!scope="col"|Type
 +
!scope="col"|ICD-9 Code
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
 +
|Surgical
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|81.51
 +
|Total Hip Replacement, Right
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|Completed
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|02/14/2010
 +
|----
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|Cardiac
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|37.21
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|Cardiac catheterization
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|Completed
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|05/05/2002
 +
|----
 +
|----
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!scope="col"|Type
 +
!scope="col"|CPT Code*
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!scope="col"|Procedure
 +
!scope="col"|Status
 +
!scope="col"|Date Performed
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|----
 +
|Surgical
 +
|27130
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|Total Hip Replacement, Right
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|Completed
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|02/14/2010
 +
|----
 +
|Cardiac
 +
|93501
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|Cardiac catheterization
 +
|Completed
 +
|05/05/2002
 +
|----
 +
--[[User:Glilly|Glilly]] 11:35, 22 Nov 2010 (PST)

Revision as of 19:35, 22 November 2010

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