Patient Summary:
This is a 68-year-old white man with a history of diabetes, hypertension, and heart failure, who
presented to the emergency room with the chief complaint of increasing weakness, cough, chest pain,
and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss.
He has mild anorexia.
Lab tests:
• Serum glucose: 250 mg/dL
• White count: 25,000
Current medications:
• Metformin Oral Tablet 500mg 3x day
• Enalapril Oral Tablet 10mg twice daily
For the above patient summary we can clearly divide the same into 3 sections: previous and current
diagnosis, laboratory results and medications being taken.
Previous and current Conditions:
For the previous and the current conditions as mentioned in the patient summary I used the ICD-9 and
the UMLS Terminology Services Metathesaurus Browser for finding the diagnosis codes.
ICD-9:
-
Diabetes:
Diabetes | 250.0 | ICD-9 | Diabetes mellitus without mention of complication
Diabetes | C0011849 | UMLS | Diabetes Mellitus
-
Hypertension:
Hypertension | 416.0 | ICD-9 | Primary pulmonary hypertension
Hypertension | C0020542 | UMLS | Pulmonary Hypertension
-
Heart Failure:
Heart Failure | 428.0 | ICD -9 | Congestive heart failure, unspecified
Heart Failure | C0018801 | UMLS | Heart Failure
-
Increasing weakness:
Increased Weakness | 780.79 | ICD-9 | Other malaise and fatigue
Increased Weakness | C1883552 | UMLS | Weakness
-
Cough:
Cough |786.2 | ICD-9 | Cough
Cough | C0010200 | UMLS | Coughing
-
Chest pain:
Chest Pain |786.05 | ICD -9 | Shortness of breath (Choose this one as the patient is also
having dyspnea)
Chest Pain | C0008031 | UMLS | Chest Pain
-
Dyspnea on exertion:
Dyspnea on exertion | 786.09 I ICD-9 | Other respiratory abnormalities
Dyspnea on exertion | C0231807 I UMLS | Dyspnea on exertion
-
Weight loss:
Weight Loss | 783.2 | ICD-9 | Abnormal loss of weight and underweight
Weight Loss | C0043096 | UMLS | Body Weight decreased
-
Anorexia:
Anorexia | 783.0 I ICD-9 | Anorexia
Anorexia | C0003123 I UMLS | Anorexia
Laboratory Tests:
For the laboratory test I used the LOINC web browser and the UMLS Terminology Services
Metathesaurus Browser for finding the diagnosis codes.
-
Serum glucose: 250 mg/dL
Serum Glucose | 2345-7 | LOINC | Glucose [Mass/volume] in Serum or Plasma
Range – 74-106 mg/dL ()
Serum Glucose | C0202041 | UMLS | Glucose measurement, serum
-
White count: 25,000
White Count | 6690-2 | LOINC | Leukocytes [#/volume] in Blood by Automated Count
White Count | C1271681 | UMLS | Total white Blood Count
Medications:
For Medications I used the RxNav which is provided by the Unites States National Library of Medicine
(NLM). RxNav serves as a browser for RxNorm and helps in browsing the RxNorm names and codes in a
user friendly manner.
-
Metformin Oral Tablet 500mg 3x day
Searched in RxNav as a string and used the simplified view to see the results. Got the following
information by clicking on the RxTerms tab.
Metformin | 861007 | RxNorm | Metformin hydrochloride 500 MG Oral Tablet
By clicking on the NDF-RT tab and clicking on the Relations Table I was able to see the disease for which
this medication is being taken. As the patient has a history of diabetes so this medication was prescribed
earlier.
Retrieved from RxNorm Navigator (http://rxnav.nlm.nih.gov/rxnav.jnlp)
-
Oral Tablet 10mg twice daily
Searched in RxNav as a string and used the simplified view to see the results. Got the following
information by clicking on the RxTerms tab.
Enalapril | 858817 | RxNorm | Enalapril Maleate 10 MG Oral Tablet
By clicking on the NDF-RT tab and clicking on the Relations Table I was able to see the disease for which
this medication is being taken. As the patient has a history of hypertension and heart failure so this
medication was prescribed earlier.
Retrieved from RxNorm Navigator (http://rxnav.nlm.nih.gov/rxnav.jnlp)
RxNorm:
RxNorm is a standard nomenclature developed by the Unites States National Library of Medicine (NLM).
The representation of various medications in the in the simplified corresponds to the way in which a
physician will view the drug/prescribe the drug. The NLM uses the various government and commercial
data available for creating the normalized names of drugs and to come up with the list of all the drugs
used in the Unites States. RxNav serves as a browser for RxNorm and helps in browsing the RxNorm
names and codes in a user friendly manner.
The browser has the following advantages:
-
It is easy to use due to its graphical interface.
The information about a particular drug can be viewed easily by a non healthcare professional in
the simplified view. It actually helped me getting more information for this assignment.
The NDF-RT section on the browser is really helpful. It provides a concise view of the drug and
the various diseases it can treat or prevent. This is really helpful for non healthcare professional
to gain more information.
The browser in my opinion may need the following:
-
The various abbreviations and definitions used needs to be put in a help file. It will help the non
healthcare professionals to better understand the information presented. For my assignment I
had to look up various abbreviations on the RxNav browser on the web.
ICD-9:
The ICD-9 code browser had a simple interface and easy to understand. The browser uses custom google
search and it helps in faster retrieval of data. While looking for the diagnosis codes for various previous
conditions and current complaints it took to running the search for information more than once. The
data provided by the search although concise and current required more filtering to get to the
appropriate codes. For a new user it will require some amount of work to find out the correct codes.
LOINC:
The browser provided by LOINC to search the various laboratory related clinical terminologies and
observations is easy to use. It has a very simple interface. Searching specific terms provides the result in
a spreadsheet form. But the searching is complex as it would require substantial knowledge of the
various terms. While searching for White Count I was unable to get any close match and it was providing
me with result that had a white blood cells count as a component. In orders for us to get the appropriate
code for white count I had look for the clinical name for the same which was Leukocytes [#/volume] in
Blood by Automated Count. It would be great if the browser can be simplified and it should have filters
set up so that any one searching for the codes would find it easily rather than having to go through
pages of clinical terms.
UMLS:
http://www.nlm.nih.gov/research/umls/about_umls.html
References:
UTS — https://uts.nlm.nih.gov/uts.html
RxNorm Navigator — http://rxnav.nlm.nih.gov/rxnav.jnlp
ICD9-CM — http://www.icd9data.com/2011/Volume1/
LOINC — http://search.loinc.org/