CCD SCENARIO – C-CDA 2.1 FULL
Scenario - C-CDA 2.1 Full
Introduction
Since being a teenager, Luisa has unfortunately been susceptible to severe migraines. She has
had various treatments over the years but now manages her condition by lifestyle
management, prophylactic propranolol and the use of zolmitriptan for symptomatic treatment
of any migraine that occurs.
At a previous surgery, Luisa was treated with Enoxaparin to counter a concern about
thromboembolisms. She experienced a serious adverse drug reaction to the Enoxaparin.
In February 2015, Luisa suffers a severe urinary tract infection and visits her gynaecologist, Dr.
Hoffman, seeking treatment. Luisa’s symptoms are such that Dr Hoffman wishes to commence
antibiotic treatment straight away and intends to prescribe ciprofloxacin. She uses her clinical
system to issue the prescription. Dr. Hoffman is aware that Luisa has suffered from migraines
since her teenage years, as it was a consideration when selecting a suitable method of
contraception for Luisa, but she is not aware of the exact therapy that Luisa has.
Header Data
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Patient
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Luisa Schmitt
Race: White
Ethnicity: Not Hispanic or Latin
Language: English
DOB: May 30, 1986
ID: 111-444-6556
Address: 804 Mulberry Street, Battle Ground, WA 98604
Home Phone: (360) 555-6785
Author
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Dr. Gretchen Hoffman
Address: 720 W Main Street, Battle Ground, WA 98604
Phone: (360) 555-6491
JANUARY 2016 HL7 IMPLEMETATION-A-THON
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CCD SCENARIO – C-CDA 2.1 FULL
Sections
Allergies and Intolerances
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Enoxaparin (anaphylaxis) since November 23, 2013
Medications
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Propranolol 40mg Tablets: 1 tablet twice daily (July 17, 2008 - now)
Zolmitriptan 5mg Tablets: 1 tablet as needed to relieve migraines (since November 15,
2015)
Micronor 350mcg Tablets: 1 tablet daily (February 9, 2010 - now)
Problem
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Severe Migraines first noted November 15, 2015
Urinary Tract Infection first noted February 20, 2010
Procedures
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Childbirth - June 20, 2013
Results
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February 20, 2015 - Urinanalysis: Color Yellow, Appearance Hazy, Glucose NEG, Bilirubin
NEG, Ketone NEG, Spec Grav 1.017, Blood TRACE, PH 6.0, Protein NEG, Nitrite POS, Leuk
Esterase 2+, Microscopic Indicated? Yes
February 20, 2015 - Urine Microscopic: RBC OCCASIONAL, WBC 20-30, Epithelial Cells 15 Squamous, Bacteria 4+, Urine Culture Indicated? Yes
February 20, 2015 - Urine Culture: POSITIVE, 126500 CFU/mL
Vital Signs
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February 18, 2015 - Blood pressure of 132/85 mmHg
February 18, 2015 - Height of 163 cm
February 18, 2015 - Weight of 68.5 kg
Advance Directives
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The patient wishes to donate their organs (March 1, 2010)
JANUARY 2016 HL7 IMPLEMETATION-A-THON
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CCD SCENARIO – C-CDA 2.1 FULL
Encounters
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Severe Urinary Tract Infection, Dr. Gretchen Hoffman of Good Health Gynaecology
Clinic, February 18, 2015
Childbirth, Good Health Hospital, June 20, 2013
Family History
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Patient's grandmother reported occasional headaches.
Patient's father, mother, brother and two sisters are all in good health.
Functional Status
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Patient is normal as determined during interview on February 15, 2015
Immunizations
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HPV: 1st Dose November 7, 1997
HPV: 2nd dose: December 21, 1997
Medical Equipment
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None
Mental Status
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As of February 15, 2015 the patient has no mental concerns.
Nutrition
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As of February 15, 2015 the patient is well nourished and has not been following any
specific diets.
Payers
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Good Health Insurance: Extended Healthcare (#1138345) (Patient is insured)
Plan of Treatment
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Patient self-treats with Zolmitriptan along with a regular course of Propranolol for the
migraines
Treat the UTI with Ciprofloxacin; use Clotrimazole if thrush (vaginal candidiasis)
develops.
JANUARY 2016 HL7 IMPLEMETATION-A-THON
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