Initial Public Health Case Report
Jane Stinn
Patient Identifiers
123453 Meaningless identifier, not to be used for any actual entities. Examples only.
111-00-1234 United States Social Security Number

About

Date of Birth
11/24/1974
Sex
Female
Race
White
Ethnicity
Not Hispanic or Latino

Contact

Home

5101 Peachtree St NE

Atlanta, GA

30302, US

Tel
+1-(404)555-1212

Author

Acme EHR

Contact

4646 Brown Rd

Salem, MA

02368, US

Tel
+1-(555)555-1212;ext=9998

Encounter

Identifier
9937012 OID: 2.16.840.1.113883.19
Type
Office outpatient visit 15 minutes
Date
From: 11/7/2016
To: 11/7/2016
Location
Outpatient facility

Responsible Party

Michael Coletta, M.D. of BMass Doctors

Contact

2100 North Ave

Burlington, MA

02368, US

Tel
+1(555)555-1003

Plan of Treatment

Initial Case Report Trigger Code Lab Test Order Trigger Code Trigger Code codeSystem RCTC OID RCTC Version Ordered Date
Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method 80825-3 LOINC 2.16.840.1.114222.4.11.7508 19/05/2016 NOV 8, 2016

Encounters

Encounter Date(s) Location
Office outpatient visit 15 minutes NOV 7, 2016
  • Urgent Care Center
  • Encounter Diagnosis Type
    Diagnosis
    • Initial Case Report Trigger Code Problem Observation Problem Trigger Code Trigger Code codeSystem RCTC OID RCTC Version Date(s)
      Diagnosis Pertussis (disorder) 282291009 SNOMED CT 2.16.840.1.114222.4.11.7508 19/05/2016 NOV 7, 2016
      Encounter Diagnosis Type
      Diagnosis
      • Problem Type Problem Date(s)
        Diagnosis A non-trigger code diagnosis (disorder) NOV 7, 2016

History of Present Illness

Persistent Cough REPORTED starting on 2016/10/05
Whooping Respiration not reported
Paroxysms Of Coughing REPORTED starting on 2016/11/04
Post-tussive vomiting not reported

Medications Administered

Medication Dose Duration Route
Azithromycin 500 MG Oral Tablet 1 g NOV 7, 2016 11:60 ORAL

Problems

Concern Concern Status Date(s)
Problem active NOV 7, 2016
  • Problem Type Problem Date(s)
    Symptom Dark stools (finding) NOV 1, 2016
    Complaint Paroxysmal cough (finding) NOV 4, 2016
Concern Concern Status Date(s)
Problem active MAY 23, 2016
  • Problem Type Problem Date(s)
    Diagnosis Patient currently pregnant (finding) MAY 23, 2016

Reason for Visit

Dark stools

Results

Results Panel Date(s)
CBC W Auto Differential panel in Blood NOV 7, 2016 to NOV 7, 2016
  • Test Outcome Interpretation Date(s) Reference Range Reference Range Interpretation Reference Range Description
    Hematocrit 35.3 % Low NOV 7, 2016 34.9 % to 44.5 % Low Low
    Lymphocytes [#/​volume] in Blood by Automated count 5.2 10*3/uL High NOV 7, 2016 1.0 10*3/uL to 4.8 10*3/uL Normal
Results Panel Date(s)
Bordetella pertussis Ab [Units/volume] in Serum NOV 7, 2016 to NOV 7, 2016
  • Initial Case Report Trigger Code Result Observation Trigger Code Trigger Code codeSystem RCTC OID RCTC Version Outcome Interpretation Date(s) Reference Range Reference Range Interpretation
    Bordetella pertussis Ab [Units/volume] in Serum 11585-7 LOINC 2.16.840.1.114222.4.11.7508 19/05/2016 100 [iU]/mL High NOV 7, 2016 to 45 [iU]/mL Normal
Results Panel Date(s)
Bordetella pertussis [Presence] in Throat by Organism specific culture NOV 7, 2016 to NOV 7, 2016
  • Initial Case Report Trigger Code Result Observation Trigger Code Trigger Code codeSystem RCTC OID RCTC Version Outcome Trigger Code Trigger Code codeSystem RCTC OID RCTC Version Interpretation Date(s)
    Bordetella pertussis [Presence] in Throat by Organism specific culture 548-8 LOINC 2.16.840.1.114222.4.11.7508 19/05/2016 Bordetella pertussis (organism) 5247005 SNOMED CT 2.16.840.1.114222.4.11.7508 19/05/2016 Abnormal NOV 7, 2016

Social History

Birth Sex Value Date
Sex Assigned At Birth Female NOV 24, 1974
Social History Observation Type Value Date(s)
Employment detail Centers for Disease Control 1, Peachtree St South Atlanta, GA, 404-564-7865 JAN 1, 1993
Travel History: Date(s) Notes Location
1999 to 2007 Spent 8 years in the UK during the BSE outbreak
In the 3 weeks before NOV 9, 2016
  • Brazil
APR 29, 2016 to OCT 30, 2016
  • Nadi, FJ
MAY 6, 2016 to MAY 15, 2016
  • Montreal, QC, CA
JUL 13, 2016 to JUL 15, 2016
  • Sydney, NSW, AU
OCT 22, 2016 to OCT 30, 2016
  • 1170 N Rancho Robles Rd Oracle, AZ8562, US

Document maintained by

Salem Medical Center

Contact

4646 Brown Rd

Salem, MA

02368, US

Tel
+1(555)555-1212

Document Information

Document Identifier Document Created
OID: db734647-fc99-424c-a864-7e3cda82e703 11/7/2016, 09:44