NIST-Inpatient-test-patient-4
From VistApedia
Revision as of 13:57, 4 April 2012 by NeilArmstrong (talk | contribs) (Added a glossary link to Record~)
Patient Summary Record Test Data – Set #4
| Patient | |||||
|---|---|---|---|---|---|
| Name | Date/Time of Birth | Gender | Identification Number | Identification Number Type | Address/Phone |
| Paul Jackson | 03/08/1962 14:25:50 |
Male | 998777349 | Medical Record Number | 754 Samuel Street, Blanchard, Oklahoma 73010 405-228-9292 |
“Source” for all data for this patient: Mary Pfiffer, MD
| Problem List | |||||
|---|---|---|---|---|---|
| Type | ICD-9 Code | Patient Problem | Status | Date Diagnosed | |
| Diagnosis | 410.90 | Acute Myocardial Infarction | Resolved | 07/12/2010 | |
| Finding | 414.01 | Coronary Artery Disease (CAD) | Chronic | 07/05/2000 | |
| Type | SNOMED Code* | Patient Problem | Status | Date Diagnosed | |
| Disorder | 57054005 | Acute Myocardial Infarction | Resolved | 07/12/2010 | |
| Disorder | 53741008 | Coronary Arteriosclerosis | Chronic | 07/05/2000 | |
| Medication List | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| RxNorm Code | Product | Generic Name | Brand Name | Strength | Dose | Route | Frequency | Date Started | Status |
| 198039 | Medication | nitroglycerin | Nitroglycerin | 400 mcg | 1 Tablet | SL | As needed | 07/15/2010 | Active |
| 309362 | Medication | clopidogrel | Plavix | 75 mg | 1 Tablet | PO | QD | 07/05/2000 | Active |
| 197361 | Medication | amlodipine | Norvasc | 5 mg | 1 Tablet | PO | QD | 07/05/2000 | Active |
| Medication Allergy List | ||||
|---|---|---|---|---|
| Type | SNOMED Code | Medication/Agent | Reaction | Date Recorded |
| Drug Allergy | 91936005 | Penicillin | Rash and anaphylaxis | 07/12/2010 |
| Drug Allergy | 294506009 | Ampicillin | Diarrhea, nausea, vomiting | 03/28/2000 |
| Diagnostic Test Results | ||||
|---|---|---|---|---|
| Type | LOINC Code | Test (Normal Range) | Result | Date Performed |
| Chemistry | 14647-2 | Total cholesterol (<200 mg/dl) | 220 mg/dl | 07/15/2010 |
| Chemistry | 14927-8 | Triglycerides (<150 mg/dl) | 165 mg/dl | 07/15/2010 |
| Imaging | 42272-5 | Chest X-ray, PA & Lateral | The heart outline is slightly enlarged, the hilar and mediastinal vessels are of normal appearance |
07/15/2010 |
| Hematology | 718-7 | Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) | 12.8 g/dl | 2/18/2010 |
| Hematology | 4544-3 | Hematocrit (male: 40-54% female: 36-48%) | 44% | 2/18/2010 |
| Procedure List | ||||
|---|---|---|---|---|
| Type | ICD-9 Code | Procedure | Status | Date Performed |
| Cardiac | 00.66 | Percutaneous transluminal coronary angioplasty | Completed | 07/15/2010 |
| Type | CPT Code* | Procedure | Status | Date Performed |
| Cardiac | 92982 | Percutaneous transluminal coronary angioplasty | Completed | 07/15/2010 |
--Glilly 10:57, 22 Nov 2010 (PST)
