source: hData/trunk/test-patients/NIST-Ambulatory-test-patient-1-wiki.txt@ 1057

Last change on this file since 1057 was 1024, checked in by George Lilly, 14 years ago

wiki conversion of NIST Inpatient test cases completed

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Line 
1 * indicates alternative standard code per certification criteria
2
3Patient Summary Record Test Data – Set #1
4
5{| border="1"|
6!colspan="6"|Patient
7|----
8!scope="col"|Name
9!scope="col"|Date/Time of Birth
10!scope="col"|Gender
11!scope="col"|Identification Number
12!scope="col"|Identification Number Type
13!scope="col"|Address/Phone
14|----
15|John D. Smith
16|07/04/1960 10:15:02
17|Male
18|999999999
19|Medical Record Number
20|355 Maple Street <br>Williamsport, <br>Pennsylvania 17701 <br>570-837-8364
21|----
22|}
23
24“Source” for all data for this patient: John Fitzgerald, MD
25
26{| border="1"|
27!colspan="6"|Problem List
28|----
29!scope="col"|Type
30!scope="col"|ICD-9 Code
31!scope="col"|Patient Problem
32!scope="col"|Status
33!scope="col"|Date Diagnosed
34|----
35|Diagnosis
36|250.02
37|Diabetes Mellitus, Type 2
38|Active
39|09/16/2009
40|----
41|Condition
42|272.4
43|Hyperlipidemia
44|Active
45|05/05/2002
46|----
47|Finding
48|414.01
49|Coronary Artery Disease (CAD)
50|Chronic
51|05/05/2002
52|----
53|Symptom
54|401.9
55|Hypertension, Essential
56|Active
57|05/05/2002
58|----
59|----
60!scope="col"|Type
61!scope="col"|SNOMED Code*
62!scope="col"|Patient Problem
63!scope="col"|Status
64!scope="col"|Date Diagnosed
65|----
66|Disorder
67|44054006
68|Diabetes Mellitus, Type 2
69|Active
70|09/16/2009
71|----
72|Disorder
73|55822004
74|Hyperlipidemia
75|Active
76|05/05/2002
77|----
78|Disorder
79|53741008
80|Coronary Arteriosclerosis
81|Chronic
82|05/05/2002
83|----
84|Disorder
85|59621000
86|Essential Hypertension
87|Active
88|05/05/2002
89|----
90|}
91
92{| border="1"|
93!colspan="10"|Medication List
94|----
95!scope="col"|RxNorm Code
96!scope="col"|Product
97!scope="col"|Generic Name
98!scope="col"|Brand Name
99!scope="col"|Strength
100!scope="col"|Dose
101!scope="col"|Route
102!scope="col"|Frequency
103!scope="col"|Date Started
104!scope="col"|Status
105|----
106|205875
107|Medication
108|glyburide
109|Diabeta
110|2.5 mg
111|1 Tablet
112|PO
113|Q AM
114|09/16/2009
115|Active
116|----
117|617314
118|Medication
119|atorvastatin calcium
120|Lipitor
121|10 mg
122|1 Tablet
123|PO
124|Q Day
125|05/05/2002
126|Active
127|----
128|200801
129|Medication
130|furosemide
131|Lasix
132|20 mg
133|1 Tablet
134|PO
135|BID
136|05/05/2002
137|Active
138|----
139|628958
140|Medication
141|potassium chloride
142|Klor-Con
143|10 mEq
144|1 Tablet
145|PO
146|BID
147|05/05/2002
148|Active
149|----
150|}
151
152{| border="1"|
153!colspan="5"|Medication Allergy List
154|----
155!scope="col"|Type
156!scope="col"|SNOMED Code
157!scope="col"|Medication/Agent
158!scope="col"|Reaction
159!scope="col"|Date Recorded
160|----
161|Drug Allergy
162|293597001
163|Codeine
164|Hives
165|06/27/1996
166|----
167|Drug Allergy
168|294506009
169|Ampicillin
170|Diarrhea, nausea, vomiting
171|03/15/1994
172|----
173|}
174
175{| border="1"|
176!colspan="5"|Diagnostic Test Results
177|----
178!scope="col"|Type
179!scope="col"|LOINC Code
180!scope="col"|Test (Normal Range)
181!scope="col"|Result
182!scope="col"|Date Performed
183|----
184|Chemistry
185|14771-0
186|Fasting Blood Glucose (70–100 mg/dl)
187|178 mg/dl
188|09/16/2009
189|----
190|Chemistry
191|14682-9
192|Creatinine (0.5–1.4 mg/dl)
193|1.0 mg/dl
194|09/16/2009
195|----
196|Chemistry
197|14937-7
198|BUN (7–30 mg/dl)
199|18 mg/dl
200|09/16/2009
201|----
202|Chemistry
203|2951-2
204|Sodium (135–146 mg/dl)
205|141 mg/dl
206|09/16/2009
207|----
208|Chemistry
209|2823-3
210|Potassium (3.5–5.3 mg/dl)
211|4.3 mg/dl
212|09/16/2009
213|----
214|Chemistry
215|14647-2
216|Total cholesterol (<200 mg/dl)
217|162 mg/dl
218|09/16/2009
219|----
220|Chemistry
221|14646-4
222|HDL cholesterol (?40 mg/dl)
223|43 mg/dl
224|09/16/2009
225|----
226|Chemistry
227|2089-1
228|LDL cholesterol (<100 mg/dl)
229|84 mg/dl
230|09/16/2009
231|----
232|Chemistry
233|14927-8
234|Triglycerides (<150 mg/dl)
235|177 mg/dl
236|09/16/2009
237|----
238|Imaging
239|24648-8
240|Chest X-ray, PA
241|No disease is seen in the<br>lung fields or pleura
242|09/16/2009
243|----
244|}
245
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