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

2.5 KiB
Raw Permalink Blame History

1Patient Summary Record Test Data Set #5
2Patient
3Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
4Christine Taylor|09/22/1965 16:48:25|Female|9787478034|Medical Record Number|754 Angel Street Marshalltown Iowa 50158 641-544-9988
5“Source” for all data for this patient: Kathryn Thomson, MD
6Problem List
7Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
8Diagnosis|540.0|Acute Appendicitis|Resolved|01/09/2010
9Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
10Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/30/2009
11Symptom|401.9|Hypertension, Essential|Chronic|02/25/2008
12Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
13Disorder|74400008|Appendicitis|Resolved|01/09/2010
14Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
15Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/30/2009
16Disorder|59621000|Essential Hypertension|Chronic|02/25/2008
17Medication List
18RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
19309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active
20205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/30/2009|Active
21209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|03/30/2009|Active
22200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/25/2008|Active
23628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2008|Active
24884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|02/25/2008|Active
25Medication Allergy List
26Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
27Drug Allergy|293620004|Indomethacin|Rash, dizziness, headache|06/05/2008
28Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|05/25/1997
29Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|08/25/1989
30Diagnostic Test Results
31Type|LOINC Code|Test (Normal Range)|Result|Date Performed
32Chemistry|14771-0|Fasting Blood Glucose (70100 mg/dl)|126 mg/dl|07/15/2010
33Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.3 mg/dl|07/15/2010
34Chemistry|14927-8|Triglycerides (<150 mg/dl)|178 mg/dl|07/15/2010
35Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal<br> and the hilar and mediastinal<br> vessels are of normal appearance|02/25/2008
36Procedure List
37Type|ICD-9 Code|Procedure|Status|Date Performed
38Surgical|47.09|Emergency Appendectomy|Completed|01/09/2010
39Type|CPT Code*|Procedure|Status|Date Performed
40Surgical|44950|Emergency Appendectomy|Completed|01/09/2010