source: hData/trunk/test-patients/IP-test-patient-1.txt@ 1020

Last change on this file since 1020 was 1019, checked in by George Lilly, 14 years ago

text form of test patients from NIST MU test scripts

File size: 6.3 KB
Line 
1TD170.306.f.: Exchange clinical information and patient summary record
2
3* indicates alternative standard code per certification criteria
4
5Patient Summary Record Test Data – Set #1
6
7Patient
8 Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
9Ann Toliver 07/16/1950 Female 989285998 Medical Record Number 353 Wine Street
10 14:15:12 Flint,
11 Michigan 48503
12 810-673-8378
13
14“Source” for all data for this patient: Fatima Goyal, MD
15
16Problem List
17 Type ICD-9 Code Patient Problem Status Date Diagnosed
18Diagnosis 428.0 Congestive Heart Failure Active 02/22/2010
19Diagnosis 410.90 Acute Myocardial Infarction Resolved 09/16/2007
20
21 Type SNOMED Code* Patient Problem Status Date Diagnosed
22Disorder 42343007 Congestive Heart Failure Active 02/22/2010
23Disorder 57054005 Acute Myocardial Infarction Resolved 09/16/2007
24
25Medication List
26 RxNorm
27 Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
28 Code
29201372 Medication captopril Capoten 25 mg Tablet PO TID 02/25/2010 Active
30200820 Medication spironolactone Aldactone 25 mg Tablet PO QID 02/25/2010 Active
31309888 Medication digoxin Lanoxin 125 mcg Tablet PO QD 02/25/2010 Active
32 potassium
33628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 02/25/2010 Active
34 chloride
35198039 Medication nitroglycerin Nitroglycerin 400 mcg 1 Tablet SL As needed 09/20/2007 Active
36
37Medication Allergy List
38 Type SNOMED Code Medication/Agent Reaction Date Recorded
39Drug Allergy 293586001 Aspirin Wheezing 03/02/2007
40Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 04/25/1994
41
42Diagnostic Test Results
43 Type LOINC Code Test (Normal Range) Result Date Performed
44 Enlarged cardiac silhouette,
45Imaging 24648-8 Chest X-ray, PA 02/24/2010
46 lung fields clear
47Chemistry 2951-2 Sodium (135–146 mg/dl) 138 mg/dl 02/24/2010
48Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 4.3 mg/dl 02/24/2010
49Chemistry 2075-0 Chloride (95-107 mEq/L) 98 mEq/L 02/24/2010
50 Enlarged cardiac silhouette,
51Imaging 24648-8 Chest X-ray, PA horizontal lines in the periphery 02/22/2010
52 of lower posterior lung fields
53Chemistry 2951-2 Sodium (135–146 mg/dl) 126 mg/dl 02/22/2010
54Chemistry 2823-3 Potassium (3.5–5.3 mg/dl) 3.0 mg/dl 02/22/2010
55Chemistry 2075-0 Chloride (95-107 mEq/L) 94 mEq/L 02/22/2010
56
57Procedure List
58 Type ICD-9 Code Procedure Status Date Performed
59Cardiac 00.66 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
60Cardiac 37.21 Cardiac catheterization Completed 10/01/2006
61
62 Type CPT Code* Procedure Status Date Performed
63Cardiac 92982 Percutaneous transluminal coronary angioplasty Completed 09/17/2007
64Cardiac 93501 Cardiac catheterization Completed 10/01/2006
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