Patient Summary (HL7 CCD)

Document Effective: 10/28/2015 13:27

Encounter Dates:10/24/2015 through 10/28/2015

Contents
Patient Demographics
Care Team
Provider Organization
Vital Signs
Allergies
Procedures
History of Immunizations
Problems
Results
Active Medications
Medications Administered During Visit
Encounters
Social History
Patient Decision Aids
Discharge Instructions
Chief Complaint and Reason For Visit
Function Status
Plan of Care
Referral/Transition of Care

Patient Demographics [back to top]

NameEVA H BRISTOW
Address73 OLD COWAN SCHOOL
ROAD
ALBANY, KY 42602
Primary Home6063875884
Date of Birth11/09/1946
SexF
Race
EthnicityNot Hispanic or Latino
Language SpokenEnglish

Care Team [back to top]

NameAddressPhoneRole
TAMMY MD BROWNCLINTON FAMILY MEDICAL
606 BURKESVILLE ROAD
ALBANY, KY 42602
6063874251 (Work Place)
Attending Physician
MAZEN MD KHAYATERX 9724 KINGSTON PIKE
SUITE 1300
KNOXVILLE, TN 37922
5022288020 (Work Place)
ER Physician 1
MARK J R.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Cardiopulmonary
ELIZABETH M D.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Cardiopulmonary
DANNY L P.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Cardiopulmonary
LISA L S.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Registered Nurse
TYWLA S S.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Cardiopulmonary
Betty A.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Registered Nurse
Kailyn J.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Licensed Practical Nurse
Heather J C.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Registered Nurse
David S S.723 BURKESVILLE RD
ALBANY, KY 426021654
6063876421 (Work Place)
Licensed Practical Nurse

Provider Organization [back to top]

NameCLINTON COUNTY HOSPITAL
Address723 BURKESVILLE RD
ALBANY, KY 426021654
Work Place6063876421

Vital Signs [back to top]

Vital Sign Value Unit Date/Time Recent/Initial?
Weight Measured 211.1 lbs 10/24/2015 01:39 Initial VS
Height 67 in 10/24/2015 01:39 Initial VS
BMI (Body Mass Index) 33.06 kg/m^2 10/24/2015 01:39 Initial VS
BSA (Body Surface Area) 2.13 m^2 10/24/2015 01:39 Initial VS
BP Systolic 112 mmHg 10/24/2015 01:39 Initial VS
BP Diastolic 65 mmHg 10/24/2015 01:39 Initial VS
Respiratory Rate 20 bpm 10/24/2015 01:39 Initial VS
Heart Rate 127 bpm 10/24/2015 01:39 Initial VS
Body Temperature 104.1 degrees 10/24/2015 01:39 Initial VS
O2 % BldC Oximetry 93 % 10/24/2015 04:23 Initial VS
BP Systolic 109 mmHg 10/28/2015 09:20 Most Recent VS
BP Diastolic 55 mmHg 10/28/2015 09:20 Most Recent VS
Respiratory Rate 20 bpm 10/28/2015 09:20 Most Recent VS
Heart Rate 75 bpm 10/28/2015 09:20 Most Recent VS
O2 % BldC Oximetry 96 % 10/28/2015 09:20 Most Recent VS
Body Temperature 96.6 degrees 10/28/2015 09:20 Most Recent VS
Weight Measured 215.3 lbs 10/28/2015 09:27 Most Recent VS
Height 20.2 in 10/28/2015 09:27 Most Recent VS
BMI (Body Mass Index) 70.97 kg/m^2 10/28/2015 09:27 Most Recent VS
BSA (Body Surface Area) 1.18 m^2 10/28/2015 09:27 Most Recent VS

Allergies [back to top]

Allergy Code Allergy Type Reaction Status
CODEINE 2670 Drug allergy Active

Procedures [back to top]

Procedure Code Procedure Type Date
XR CHEST PORTABLE 399208008 SNOMED CT 10/25/2015
CT HEAD WO CONTRAST 408754009 SNOMED CT 10/23/2015
XR CHEST PORTABLE 399208008 SNOMED CT 10/23/2015

History of Immunizations [back to top]

Unknown or Not Available.

Problems [back to top]

Problem Code Start Date Resolved Date Status
Acute pyelonephritis 36689008 Active

Results [back to top]

B TYPE NATRIURETIC PEPTIDE - Collect Date/Time: 10/25/2015 05:00
Test Name Code Test Result Test Units Test Ref Range
BNP 30934-4 129 pg/mL L=0 H=100

B TYPE NATRIURETIC PEPTIDE - Collect Date/Time: 10/23/2015 21:59
Test Name Code Test Result Test Units Test Ref Range
BNP 30934-4 28 pg/mL L=0 H=100

CARDIAC TRIAGE - Collect Date/Time: 10/23/2015 21:59
Test Name Code Test Result Test Units Test Ref Range
TROPONIN I 49563-0 0.010 ng/ml L=0.000 H=0.300

FINGER GLU - Collect Date/Time: 10/27/2015 20:25
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 113 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/27/2015 16:10
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 123 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/27/2015 11:00
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 116 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/27/2015 05:00
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 137 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/26/2015 21:09
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 133 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/26/2015 16:00
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 125 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/26/2015 11:00
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 110 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/25/2015 20:45
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 116 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/25/2015 16:02
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 115 mg/dl L=65 H=105

FINGER GLU - Collect Date/Time: 10/25/2015 10:57
Test Name Code Test Result Test Units Test Ref Range
FINGER GLU 43151-0 121 mg/dl L=65 H=105

TOBRAMYCIN 12HR RANDOM - Collect Date/Time: 10/25/2015 09:36
Test Name Code Test Result Test Units Test Ref Range
TOBRAMYCIN 12HR RAND 35670-9 1.8 ug/mL L=0.5 H=10.0

TOBRAMYCIN 4HR RANDOM - Collect Date/Time: 10/25/2015 01:30
Test Name Code Test Result Test Units Test Ref Range
TOBRA 4HR 35670-9 8.9 ug/ml L=0.5 H=10.0

TRIAGE DOA - Collect Date/Time: 10/23/2015 22:51
Test Name Code Test Result Test Units Test Ref Range
AMPHETAMINES 19261-7 NEGATIVE N/A CUTOFF CONC. 1000 NG/ML
METHAMPHETAMINE 19554-5 NEGATIVE N/A CUTOFF CONC. 1000 NG/ML
BARBITUATES 19270-8 NEGATIVE N/A CUTOFF CONC. 200 NG/ML
BENZODIAZEPINE 14316-4 NEGATIVE N/A CUTOFF CONC. 300 NG/ML
COCAINE 3397-7 NEGATIVE N/A CUTOFF CONC. 300 NG/ML
OPIATES 19295-5 POSITIVE N/A CUTOFF CONC. 300 NG/ML
METHADONE 19550-3 NEGATIVE N/A CUTOFF CONC. 300 NG/ML
PROPOXYPHENE 19429-0 NEGATIVE N/A CUTOFF CONC. 300 NG/ML
THC 18282-4 NEGATIVE N/A CUTOFF CONC. 50 NG/ML
TRICYCLIC 19312-8 NEGATIVE N/A CUTOFF CONC. 300 NG/ML
PROCEDURAL CNT CONFIRMED N/A

CBC - Collect Date/Time: 10/28/2015 05:00
Test Name Code Test Result Test Units Test Ref Range
WBC 6690-2 6.80 th/ul L=4.80 H=10.80
RBC 789-8 2.86 mil/ul L=4.20 H=5.40
HEMOGLOBIN 718-7 8.7 g/dl L=12.0 H=16.0
HEMATOCRIT 4544-3 26.9 % L=37.0 H=47.0
MCV 787-2 94 fl L=81 H=99
MCH 785-6 31 pg L=27 H=31
MCHC 786-4 32 g/dl L=33 H=37
RDW 788-0 14.0 % L=11.5 H=14.5
PLATELET CT 777-3 235 th/ul L=130 H=400
MPV 32623-1 8.1 fl L=7.4 H=10.4
NE% 770-8 44.1 % L=43.0 H=65.0
LYMPH % 736-9 36.3 % L=20.5 H=51.1
MONO % 5905-5 12.9 % L=1.7 H=9.3
EO% 713-8 5.2 % L=0.9 H=2.9
BA% 706-2 1.5 % L=0.2 H=1.0
NE# 751-8 3.0 th/ul L=2.2 H=4.8
LYMPH # 731-0 2.5 th/ul L=1.2 H=3.4
MONO # 742-7 0.9 th/ul L=0.1 H=0.5
EO# 711-2 0.4 th/ul L=0.0 H=0.2
BA# 704-7 0.1 th/ul L=0.0 H=0.1
Manual Diff 24318-8 Not Indicated N/A

CBC - Collect Date/Time: 10/26/2015 05:00
Test Name Code Test Result Test Units Test Ref Range
WBC 6690-2 15.40 th/ul L=4.80 H=10.80
RBC 789-8 3.31 mil/ul L=4.20 H=5.40
HEMOGLOBIN 718-7 10.1 g/dl L=12.0 H=16.0
HEMATOCRIT 4544-3 31.2 % L=37.0 H=47.0
MCV 787-2 94 fl L=81 H=99
MCH 785-6 31 pg L=27 H=31
MCHC 786-4 33 g/dl L=33 H=37
RDW 788-0 13.7 % L=11.5 H=14.5
PLATELET CT 777-3 196 th/ul L=130 H=400
MPV 32623-1 8.4 fl L=7.4 H=10.4
NE% 770-8 67.9 % L=43.0 H=65.0
LYMPH % 736-9 19.2 % L=20.5 H=51.1
MONO % 5905-5 10.8 % L=1.7 H=9.3
EO% 713-8 0.9 % L=0.9 H=2.9
BA% 706-2 1.2 % L=0.2 H=1.0
NE# 751-8 10.5 th/ul L=2.2 H=4.8
LYMPH # 731-0 3.0 th/ul L=1.2 H=3.4
MONO # 742-7 1.7 th/ul L=0.1 H=0.5
EO# 711-2 0.1 th/ul L=0.0 H=0.2
BA# 704-7 0.2 th/ul L=0.0 H=0.1
SEGS 730-2 74 %
LYM 737-7 20 %
MONO 744-3 6 %
Manual Diff 24318-8 See Below N/A

CBC - Collect Date/Time: 10/25/2015 05:00
Test Name Code Test Result Test Units Test Ref Range
WBC 6690-2 24.00 th/ul L=4.80 H=10.80
RBC 789-8 3.62 mil/ul L=4.20 H=5.40
HEMOGLOBIN 718-7 11.1 g/dl L=12.0 H=16.0
HEMATOCRIT 4544-3 34.0 % L=37.0 H=47.0
MCV 787-2 94 fl L=81 H=99
MCH 785-6 31 pg L=27 H=31
MCHC 786-4 33 g/dl L=33 H=37
RDW 788-0 14.0 % L=11.5 H=14.5
PLATELET CT 777-3 223 th/ul L=130 H=400
MPV 32623-1 8.3 fl L=7.4 H=10.4
NE% 770-8 76.0 % L=43.0 H=65.0
LYMPH % 736-9 13.6 % L=20.5 H=51.1
MONO % 5905-5 7.6 % L=1.7 H=9.3
EO% 713-8 0.9 % L=0.9 H=2.9
BA% 706-2 1.9 % L=0.2 H=1.0
NE# 751-8 18.2 th/ul L=2.2 H=4.8
LYMPH # 731-0 3.3 th/ul L=1.2 H=3.4
MONO # 742-7 1.8 th/ul L=0.1 H=0.5
EO# 711-2 0.2 th/ul L=0.0 H=0.2
BA# 704-7 0.5 th/ul L=0.0 H=0.1
SEGS 730-2 86 %
LYM 737-7 10 %
MONO 744-3 4 %
Manual Diff 24318-8 See Below N/A

CBC - Collect Date/Time: 10/23/2015 21:59
Test Name Code Test Result Test Units Test Ref Range
WBC 6690-2 15.30 th/ul L=4.80 H=10.80
RBC 789-8 4.10 mil/ul L=4.20 H=5.40
HEMOGLOBIN 718-7 12.6 g/dl L=12.0 H=16.0
HEMATOCRIT 4544-3 38.4 % L=37.0 H=47.0
MCV 787-2 94 fl L=81 H=99
MCH 785-6 31 pg L=27 H=31
MCHC 786-4 33 g/dl L=33 H=37
RDW 788-0 13.4 % L=11.5 H=14.5
PLATELET CT 777-3 280 th/ul L=130 H=400
MPV 32623-1 7.8 fl L=7.4 H=10.4
NE% 770-8 80.6 % L=43.0 H=65.0
LYMPH % 736-9 9.0 % L=20.5 H=51.1
MONO % 5905-5 8.0 % L=1.7 H=9.3
EO% 713-8 0.9 % L=0.9 H=2.9
BA% 706-2 1.5 % L=0.2 H=1.0
NE# 751-8 12.3 th/ul L=2.2 H=4.8
LYMPH # 731-0 1.4 th/ul L=1.2 H=3.4
MONO # 742-7 1.2 th/ul L=0.1 H=0.5
EO# 711-2 0.1 th/ul L=0.0 H=0.2
BA# 704-7 0.2 th/ul L=0.0 H=0.1
Manual Diff 24318-8 Not Indicated N/A

C DIFF TOXIN A/B / ANTIGEN - Collect Date/Time: 10/26/2015 02:42
Test Name Code Test Result Test Units Test Ref Range
C. DIFF TOXIN A/B 34468-9 NEGATIVE N/A NORMAL: NEGATIVE
C. DIFF ANTIGEN 34712-0 NEGATIVE N/A NORMAL: NEGATIVE
PROCEDURAL CONTROL CONFIRMED N/A
Report to IFC? NO N/A

CULTURE URINE REFLEX - Collect Date/Time: 10/23/2015 22:51
Test Name Code Test Result Test Units Test Ref Range
Report to Pharm/IFC? YES N/A

URINALYSIS w REFLEX - Collect Date/Time: 10/23/2015 22:51
Test Name Code Test Result Test Units Test Ref Range
Color 5778-6 Yellow N/A
Clarity 32167-9 Clear N/A
Glucose 5792-7 Negative N/A
Bilirubin Negative N/A
Ketone 5797-6 Negative N/A
Spec Gravity 5811-5 1.010 N/A
PH 5803-2 6.0 N/A
Protein 5804-0 Negative N/A
Urobilinogen 19161-9 0.2 N/A
Nitrite 5802-4 Negative N/A
Blood 20409-9 Small H N/A
Leukocyte 5799-2 Trace N/A
MICROSCOPIC SEE BELOW N/A
WBC/HPF 5821-4 25-30 N/A
RBC/HPF 13945-1 4-6 N/A
Epith Cells 5787-7 8-10 N/A
Bacteria 25145-4 2+ N/A
CULTURE INDICATED N/A

BASIC METABOLIC PANEL - Collect Date/Time: 10/28/2015 05:00
Test Name Code Test Result Test Units Test Ref Range
SODIUM 2951-2 141 mmol/L L=137 H=145
POTASSIUM 2823-3 3.6 mmol/L L=3.6 H=5.0
CHLORIDE 2075-0 113 mmol/L L=98 H=107
tCO2 2028-9 20.0 mmol/L L=22.0 H=29.0
GLUCOSE 2345-7 106 mg/dl L=70 H=99
BUN 3094-0 13 mg/dl L=7 H=20
CREATININE 2160-0 0.8 mg/dl L=0.5 H=1.1
CALCIUM 17861-6 8.5 mg/dl L=8.4 H=10.2
AGE 30525-0 68 YRS
EST GFR NONAA 48642-3 102
RACE WHITE N/A

BASIC METABOLIC PANEL - Collect Date/Time: 10/26/2015 05:00
Test Name Code Test Result Test Units Test Ref Range
SODIUM 2951-2 138 mmol/L L=137 H=145
POTASSIUM 2823-3 3.7 mmol/L L=3.6 H=5.0
CHLORIDE 2075-0 109 mmol/L L=98 H=107
tCO2 2028-9 21.0 mmol/L L=22.0 H=29.0
GLUCOSE 2345-7 113 mg/dl L=70 H=99
BUN 3094-0 12 mg/dl L=7 H=20
CREATININE 2160-0 0.8 mg/dl L=0.5 H=1.1
CALCIUM 17861-6 8.5 mg/dl L=8.4 H=10.2
AGE 30525-0 68 YRS
EST GFR NONAA 48642-3 102
RACE WHITE N/A

COMPREHENSIVE METABOLIC PANEL - Collect Date/Time: 10/23/2015 21:59
Test Name Code Test Result Test Units Test Ref Range
GLUCOSE 2345-7 168 mg/dl L=70 H=99
BUN 3094-0 20 mg/dl L=7 H=20
SGOT 1744-2 33 U/L L=5 H=34
ALKALINE PHOS 6768-6 76 U/L L=40 H=150
SODIUM 2951-2 134 mmol/L L=137 H=145
POTASSIUM 2823-3 4.2 mmol/L L=3.6 H=5.0
CHLORIDE 2075-0 100 mmol/L L=98 H=107
tCO2 2028-9 22.0 mmol/L L=22.0 H=29.0
BILIRUBIN T 1975-2 0.4 mg/dl L=0.2 H=1.2
CREATININE 2160-0 0.8 mg/dl L=0.5 H=1.1
CALCIUM 17861-6 10.1 mg/dl L=8.4 H=10.2
TOTAL PROTEIN 2885-2 7.6 g/dl L=6.4 H=8.3
ALBUMIN 61151-7 4.5 g/dl L=3.5 H=5.0
SGPT 1744-2 52 U/L L=0 H=55
AGE 30525-0 68 YRS
EST GFR NONAA 48642-3 102
RACE WHITE N/A

Active Medications [back to top]

No Active Medications

Medications Administered During Visit [back to top]

Medication Dose Units Frequency Route Date/Time of Last Dose
NS 0.9% 1000ML CONTINUOUS IV 10/25/2015 21:56
CALMOSEPTINE OINTMENT 2.5OZ TUBE 1 APPLICATION PRN TOPICAL 10/25/2015 13:55
SWEEN CREAM : 3OZ TUBE 1 APPLICATION QSHIFT TOPICAL 10/28/2015 04:16
PIPERA/TAZO/NS IVPB: 3.375GM/NS100ML ADV 3.375 GM Q6H IVPB 10/28/2015 06:06
ACETAMINOPHEN (TYLENOL) RS : 650MG COMF 650 MG PRN Q4H PR 10/27/2015 01:51
CALCIUM 600MG WITH VITAMIN D TAB 1 TABLET X1 PO 10/24/2015 04:22
ACETAMINOPHEN (TYLENOL) TAB : 650MG 650 MG PRN Q4H PO 10/25/2015 05:30
SALINE LOCK FLUSH 10ML 10 ML AS DIRECTED IVPUSH 10/28/2015 06:06
ONDANSETRON (ZOFRAN) INJ : 4MG/2ML 4 MG PRN Q6H IVP 10/28/2015 06:06
SPIRONOLACTONE (ALDACTONE) : 50MG TAB 100 MG BID PO 10/28/2015 08:19
ASPIRIN EC TAB : 325MG 325 MG QAM PO 10/28/2015 08:19
BUDESONIDE (PULMICORT) NEB 0.25MG/2ML 1 INHALATION BID (RT NEB) RESP 10/28/2015 06:55
BYSTOLIC TAB : 5MG 10 MG QD PO 10/28/2015 08:19
CALCIUM 600MG WITH VITAMIN D TAB 1 TABLET TID PO 10/28/2015 04:16
LOSARTAN (COZAAR) TAB : 50MG 50 MG QD PO 10/28/2015 08:19
ATORVASTATIN (LIPITOR) TAB : 20MG 20 MG QAM PO 10/28/2015 08:19
GEMFIBROZIL (LOPID) TAB : 600MG 600 MG BID 0700 1630 PO 10/28/2015 06:06
LANSOPRAZOLE (PREVACID) CAP : 30MG 30 MG QD 0700 PO 10/28/2015 06:06
B COMPLEX VITAMIN TAB/CAP 1 TABLET QD PO 10/28/2015 08:19
metFORMIN (GLUCOPHAGE) TAB : 500MG 1000 MG BID 0700 1630 PO 10/28/2015 06:06
traMADol (ULTRAM) TAB : 50MG 50 MG PRN Q6H PO 10/27/2015 21:17
PATIENT'S OWN MED (SEE INSTRUCTIONS) 1 EA BID PO 10/28/2015 08:20
BROVANA (ARFORMOTEROL): 15MCG/2ML NEBS 15 MCG BID (RT NEB) NEBS 10/26/2015 20:10
TOBRAMYCIN/NS IVPB : ADULT QD DOSING 440 MG EVERY DAY IVPB 10/24/2015 21:56
TOBRAMYCIN/NS IVPB : ADULT QD DOSING 440 MG EVERY DAY IVPB 10/27/2015 21:17
DIPHEN/ATROP (LOMOTIL) TAB 2.5/0.025 1 TAB X1 PO 10/25/2015 13:38
ACETAMINOPHEN (TYLENOL) TAB : 325MG 325 MG PRN Q4H PO 10/25/2015 22:07
LOPERAMIDE CAP 2MG (COMF12YO&UP) 2 MG PRN PO 10/27/2015 17:23
ACETAMINOPHEN (TYLENOL) TAB : 650MG 325 MG PRN Q4H PO 10/28/2015 04:17
NS 0.9% 1000ML 1 EA CONTINUOUS IV 10/26/2015 10:02
KETOROLAC (TORADOL) INJ : 30MG 15 MG PRN Q8H IVP 10/27/2015 22:20
ACIDOPHILUS WITH PECTIN 1 CAPSULE TID BEFORE MEALS PO 10/28/2015 06:06

Encounters [back to top]

Encounter Diagnosis Diagnosis Code Start Date
Acute tubulo-interstitial nephritis N10 10/24/2015

Social History [back to top]

Smoking Status Code Start Date End Date
Never smoker 266919005

Patient Decision Aids [back to top]

Patient Decision Aid
PNEUMONIA
Urinary Tract Infection in Women
Weakness

Discharge Instructions [back to top]

You were admitted to CLINTON COUNTY HOSPITAL on 10/24/2015 with a principal diagnosis of Acute tubulo-interstitial nephritis.

You were discharged from CLINTON COUNTY HOSPITAL on 10/28/2015.

Should you have any questions prior to discharge, please contact a member of your healthcare team. If you have left the hospital and have any questions, please contact your primary care physician.

Chief Complaint and Reason For Visit [back to top]

Chief Complaint Date of Onset
ACUTE PYELONEPHRITIS LETHARGY

Function Status [back to top]

Unknown or Not Available.

Plan of Care [back to top]

Unknown or Not Available.

Referral/Transition of Care [back to top]

Unknown or Not Available.