VistA-hData/test-patients/NIST-Inpatient-test-patient...

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1Patient Summary Record Test Data Set #2
2Patient
3Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
4Ruth Warholde|05/20/1954<br>23:59:45|Female|9836469798|Medical Record Number|225 Park Street <br>Morton, <br>Illinois 61550<br>309-354-9385
5|
6“Source” for all data for this patient: Jackson Shoals, MD
7Problem List
8Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
9Diagnosis|780.2|Syncope and collapse, vasovagal attack|Active|02/15/2010
10Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
11Diagnosis|599.0|Urinary tract infection|Recurrent|09/22/2008
12Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|08/12/2007
13Symptom|401.9|Hypertension, essential|Chronic|05/16/2006
14Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
15Disorder|398665005|Vasovagal syncope|Active|02/15/2010
16Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
17Disorder|197927001|Recurrent urinary tract infection|Recurrent|09/22/2008
18Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|08/12/2007
19Disorder|59621000|Essential Hypertension|Chronic|05/16/2006
20Medication List
21RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
22209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|02/16/2010|Active
23205326|Medication|lisinopril|Zestril|30 mg|1 Tablet|PO|QD|07/15/2009|Active
24309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active
25197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active
26539712|Medication|nitrofurantoin|Macrobid|100 mg|1 Capsule|PO|QD|09/22/2008|No Longer Active
27836370|Medication|ipratropium bromide monhydrate|Atrovent inhaler|18 mcg/puff|2 puffs|By oral inhalation|QID|08/14/2007|Active
28884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|05/16/2006|Active
29Medication Allergy List
30Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
31Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003
32Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|07/26/1999
33Diagnostic Test Results
34Type|LOINC Code|Test (Normal Range)|Result|Date Performed
35Imaging|11539-4|CT, head|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease. |02/24/2010
36Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|13 g/dl|02/17/2010
37Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|38%|02/17/2010
38Chemistry|2951-2|Sodium (135146 mg/dl)|136 mg/dl|02/17/2010
39Chemistry|2823-3|Potassium (3.55.3 mg/dl)|3.9 mg/dl|02/17/2010
40Imaging|34534-8|Electrocardiogram|Normal Sinus Rhythm|02/15/2010
41Microbiology|630-4|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)|Negative: No growth|10/02/2008
42Procedure List
43Type|ICD-9 Code|Procedure|Status|Date Performed
44Surgical|66.39|Bilateral tubal ligation|Completed|06/14/1990
45Type|CPT Code*|Procedure|Status|Date Performed
46Surgical|58600|Bilateral tubal ligation|