source: hData/trunk/test-patients/NIST-Inpatient-test-patient-1-wiki.txt@ 1731

Last change on this file since 1731 was 1024, checked in by George Lilly, 14 years ago

wiki conversion of NIST Inpatient test cases completed

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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
7{| border="1"|
8!colspan="6"|Patient
9|----
10!scope="col"|Name
11!scope="col"|Date/Time of Birth
12!scope="col"|Gender
13!scope="col"|Identification Number
14!scope="col"|Identification Number Type
15!scope="col"|Address/Phone
16|----
17|Ann Toliver
18|07/16/1950<br>14:15:12
19|Female
20|989285998
21|Medical Record Number
22|353 Wine Street <br>Flint, <br>Michigan 48503 <br> 810-673-8378
23|----
24|}
25
26“Source” for all data for this patient: Fatima Goyal, MD
27
28{| border="1"|
29!colspan="6"|Problem List
30|----
31!scope="col"|Type
32!scope="col"|ICD-9 Code
33!scope="col"|Patient Problem
34!scope="col"|Status
35!scope="col"|Date Diagnosed
36|----
37|Diagnosis
38|428.0
39|Congestive Heart Failure
40|Active
41|02/22/2010
42|----
43|Diagnosis
44|410.90
45|Acute Myocardial Infarction
46|Resolved
47|09/16/2007
48|----
49|----
50!scope="col"|Type
51!scope="col"|SNOMED Code*
52!scope="col"|Patient Problem
53!scope="col"|Status
54!scope="col"|Date Diagnosed
55|----
56|Disorder
57|42343007
58|Congestive Heart Failure
59|Active
60|02/22/2010
61|----
62|Disorder
63|57054005
64|Acute Myocardial Infarction
65|Resolved
66|09/16/2007
67|----
68|}
69
70{| border="1"|
71!colspan="10"|Medication List
72|----
73!scope="col"|RxNorm Code
74!scope="col"|Product
75!scope="col"|Generic Name
76!scope="col"|Brand Name
77!scope="col"|Strength
78!scope="col"|Dose
79!scope="col"|Route
80!scope="col"|Frequency
81!scope="col"|Date Started
82!scope="col"|Status
83|----
84|201372
85|Medication
86|captopril
87|Capoten
88|25 mg
89|Tablet
90|PO
91|TID
92|02/25/2010
93|Active
94|----
95|200820
96|Medication
97|spironolactone
98|Aldactone
99|25 mg
100|Tablet
101|PO
102|QID
103|02/25/2010
104|Active
105|----
106|309888
107|Medication
108|digoxin
109|Lanoxin
110|125 mcg
111|Tablet
112|PO
113|QD
114|02/25/2010
115|Active
116|----
117|628958
118|Medication
119|potassium chloride
120|Klor-Con
121|10 mEq
122|1 Tablet
123|PO
124|BID
125|02/25/2010
126|Active
127|----
128|198039
129|Medication
130|nitroglycerin
131|Nitroglycerin
132|400 mcg
133|1 Tablet
134|SL
135|As needed
136|09/20/2007
137|Active
138|----
139|}
140
141{| border="1"|
142!colspan="5"|Medication Allergy List
143|----
144!scope="col"|Type
145!scope="col"|SNOMED Code
146!scope="col"|Medication/Agent
147!scope="col"|Reaction
148!scope="col"|Date Recorded
149|----
150|Drug Allergy
151|293586001
152|Aspirin
153|Wheezing
154|03/02/2007
155|----
156|Drug Allergy
157|294506009
158|Ampicillin
159|Diarrhea, nausea, vomiting
160|04/25/1994
161|----
162|}
163
164{| border="1"|
165!colspan="5"|Diagnostic Test Results
166|----
167!scope="col"|Type
168!scope="col"|LOINC Code
169!scope="col"|Test (Normal Range)
170!scope="col"|Result
171!scope="col"|Date Performed
172|----
173|Imaging
174|24648-8
175|Chest X-ray, PA
176|Enlarged cardiac silhouette, <br>lung fields clear
177|02/24/2010
178|----
179|Chemistry
180|2951-2
181|Sodium (135–146 mg/dl)
182|138 mg/dl
183|02/24/2010
184|----
185|Chemistry
186|2823-3
187|Potassium (3.5–5.3 mg/dl)
188|4.3 mg/dl
189|02/24/2010
190|----
191|Chemistry
192|2075-0
193|Chloride (95-107 mEq/L)
194|98 mEq/L
195|02/24/2010
196|----
197|Imaging
198|24648-8
199|Chest X-ray, PA
200|Enlarged cardiac silhouette, <br>horizontal lines in the periphery<br>of lower posterior lung fields
201|02/22/2010
202|----
203|Chemistry
204|2951-2
205|Sodium (135–146 mg/dl)
206|126 mg/dl
207|02/22/2010
208|----
209|Chemistry
210|2823-3
211|Potassium (3.5–5.3 mg/dl)
212|3.0 mg/dl
213|02/22/2010
214|----
215|Chemistry
216|2075-0
217|Chloride (95-107 mEq/L)
218|94 mEq/L
219|02/22/2010
220|----
221|}
222
223{| border="1"|
224!colspan="5"|Procedure List
225|----
226!scope="col"|Type
227!scope="col"|ICD-9 Code
228!scope="col"|Procedure
229!scope="col"|Status
230!scope="col"|Date Performed
231|----
232|Cardiac
233|00.66
234|Percutaneous transluminal coronary angioplasty
235|Completed
236|09/17/2007
237|----
238|Cardiac
239|37.21
240|Cardiac catheterization
241|Completed
242|10/01/2006
243|----
244|----
245!scope="col"|Type
246!scope="col"|CPT Code*
247!scope="col"|Procedure
248!scope="col"|Status
249!scope="col"|Date Performed
250|----
251|Cardiac
252|92982
253|Percutaneous transluminal coronary angioplasty
254|Completed
255|09/17/2007
256|----
257|Cardiac
258|93501
259|Cardiac catheterization
260|Completed
261|10/01/2006
262|----
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