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

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1Patient Summary Record Test Data Set #4
2Patient
3Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
4Paul Jackson|03/08/1962<br>14:25:50|Male|998777349|Medical Record Number|754 Samuel Street,<br>Blanchard, <br> Oklahoma 73010 <br>405-228-9292
5“Source” for all data for this patient: Mary Pfiffer, MD
6Problem List
7Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
8Diagnosis|410.90|Acute Myocardial Infarction|Resolved|07/12/2010
9Finding|414.01|Coronary Artery Disease (CAD)|Chronic|07/05/2000
10Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
11Disorder|57054005|Acute Myocardial Infarction|Resolved|07/12/2010
12Disorder|53741008|Coronary Arteriosclerosis|Chronic|07/05/2000
13Medication List
14RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
15198039|Medication|nitroglycerin|Nitroglycerin|400 mcg|1 Tablet|SL|As needed|07/15/2010|Active
16309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/05/2000|Active
17197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/05/2000|Active
18Medication Allergy List
19Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
20Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|07/12/2010
21Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/28/2000
22Diagnostic Test Results
23Type|LOINC Code|Test (Normal Range)|Result|Date Performed
24Chemistry|14647-2|Total cholesterol (<200 mg/dl)|220 mg/dl|07/15/2010
25Chemistry|14927-8|Triglycerides (<150 mg/dl)|165 mg/dl|07/15/2010
26Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is slightly <br>enlarged, the hilar and <br>mediastinal vessels are of <br>normal appearance |07/15/2010
27Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|12.8 g/dl|2/18/2010
28Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|44%|2/18/2010
29Procedure List
30Type|ICD-9 Code|Procedure|Status|Date Performed
31Cardiac|00.66|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010
32Type|CPT Code*|Procedure|Status|Date Performed
33Cardiac|92982|Percutaneous transluminal coronary angioplasty|Completed|07/15/2010