NIST-Inpatient-test-patient-5

Patient Summary Record Test Data – Set #5

Patient
Name	Date/Time of Birth	Gender	Identification Number	Identification Number Type	Address/Phone
Christine Taylor	09/22/1965 16:48:25	Female	9787478034	Medical Record Number	754 Angel Street Marshalltown Iowa 50158 641-544-9988

“Source” for all data for this patient: Kathryn Thomson, MD

Problem List
Type	ICD-9 Code	Patient Problem	Status	Date Diagnosed
Diagnosis	540.0	Acute Appendicitis	Resolved	01/09/2010
Diagnosis	434.91	Cerebrovascular Accident (Stroke)	Resolved	07/09/2009
Diagnosis	250.02	Diabetes Mellitus, Type 2	Active	03/30/2009
Symptom	401.9	Hypertension, Essential	Chronic	02/25/2008
Type	SNOMED Code*	Patient Problem	Status	Date Diagnosed
Disorder	74400008	Appendicitis	Resolved	01/09/2010
Disorder	230690007	Cerebrovascular Accident (Stroke)	Resolved	07/09/2009
Disorder	44054006	Diabetes Mellitus, Type 2	Active	03/30/2009
Disorder	59621000	Essential Hypertension	Chronic	02/25/2008

Medication List
RxNorm Code	Product	Generic Name	Brand Name	Strength	Dose	Route	Frequency	Date Started	Status
309362	Medication	clopidogrel	Plavix	75 mg	1 Tablet	PO	QD	07/15/2009	Active
205875	Medication	glyburide	Diabeta	2.5 mg	1 Tablet	PO	Q AM	03/30/2009	Active
209834	Medication	docusate	Colace	100 mg	1 Capsule	PO	BID	03/30/2009	Active
200801	Medication	furosemide	Lasix	20 mg	1 Tablet	PO	BID	02/25/2008	Active
628958	Medication	potassium chloride	Klor-Con	10 mEq	1 Tablet	PO	BID	02/25/2008	Active
884175	Medication	clonidine hydrochloride	Catapres	0.1 mg	1 Tablet	PO	BID	02/25/2008	Active

Medication Allergy List
Type	SNOMED Code	Medication/Agent	Reaction	Date Recorded
Drug Allergy	293620004	Indomethacin	Rash, dizziness, headache	06/05/2008
Drug Allergy	294506009	Ampicillin	Diarrhea, nausea, vomiting	05/25/1997
Drug Allergy	91939003	Sulfonamides	Hives, photosensitivity	08/25/1989

Diagnostic Test Results
Type	LOINC Code	Test (Normal Range)	Result	Date Performed
Chemistry	14771-0	Fasting Blood Glucose (70–100 mg/dl)	126 mg/dl	07/15/2010
Chemistry	2823-3	Potassium (3.5–5.3 mg/dl)	4.3 mg/dl	07/15/2010
Chemistry	14927-8	Triglycerides (<150 mg/dl)	178 mg/dl	07/15/2010
Imaging	42272-5	Chest X-ray, PA & Lateral	The heart outline is normal and the hilar and mediastinal vessels are of normal appearance	02/25/2008

Procedure List
Type	ICD-9 Code	Procedure	Status	Date Performed
Surgical	47.09	Emergency Appendectomy	Completed	01/09/2010
Type	CPT Code*	Procedure	Status	Date Performed
Surgical	44950	Emergency Appendectomy	Completed	01/09/2010

--Glilly 10:11, 21 Nov 2010 (PST)