Initial Public Health Case Report
Eve Everywoman
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
04/20/1990
Sex
Female
Race
White
Ethnicity
Hispanic or Latino

Contact

Home

2222 Home Street

Ann Arbor, MI

99999, US

Tel : +1-555-555-2003

Author

Time:
11/7/2016, 09:44
Acme EHR

Encounter

Identifier
9937012 OID: 2.16.840.1.113883.19
Type
Office outpatient visit 15 minutes
Date
From: 11/14/2017, 10:00
To: 11/14/2017, 10:15
Location
Outpatient facility

Responsible Party

Dr. Henry Seven of Level Seven Healthcare, Inc.

Contact

1002 Healthcare Drive

Ann Arbor, MI

99999, US

Tel : +1-555-555-1002

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 7, 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 Zika (disorder) 3928002 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

Fever REPORTED starting on 2016/10/05

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
    Sympton Fever NOV 4, 2016

Reason for Visit

Fever and 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)
Zika virus envelope (E) gene [Presence] in Serum by Probe and target amplification method 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) Interpretation
    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 Positive High NOV 7, 2016 Abnormal

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
Pregnancy Status Date(s)
Not Pregnant JAN 1, 2016 to NOV 7, 2016

Document maintained by

Level Seven Healthcare, Inc.

Contact

4444 Healthcare Drive

An Arbor, MI

99999, US

Tel : +1(555)555-1212

Document Information

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