This patient is a pregnant woman in the antenatal phase, with pregnancy confirmed on 12-06-2024 and an estimated delivery date of 15-03-2025. She has moderate iron deficiency anaemia, and a urinary tract infection. Laboratory findings support these conditions, showing improving RBC levels and a confirmed E. coli infection. She is receiving appropriate treatment with prenatal vitamins, iron and folic acid supplements, and nitrofurantoin. Past conditions (appendicitis) are resolved, immunizations are up to date, and lifestyle factors are favorable. A mild allergy to prawns is noted. Overall, the patient is stable and under proper clinical management.
Problem/Diagnosis Severity Status Comment Anaemia Active Urinary tract infection (UTI) Moderate Active Patient reported symptoms of UTI. MSU to confirm
Allergies and adverse reactions Document
Type Substance Date/time of onset of first reaction Manifestation Severity of reaction Comment Allergy Prawns 18:50 02/11/2024 Itchy throat Mild Pt stated had prawns with dinner and noticed itchy throat, never experienced this before
Medicine Dose Clinical Indication Status Last Updated Comment Prenatal vitamins 1 tablet daily Pregnancy Active 28/10/2024 Iron and Folic Acid 2 tablets one in morning and evening Anemia Active 04/11/2024 Nitrofurantoin 100mg 6-hourly for 5 days Urinary tract infection (UTI) Active 04/11/2024
Vaccine Date of administration Comment Diphtheria + tetanus + pertussis 5 component adolescent/adult vaccine injection, 0.5 mL syringe 05/10/2024 Influenza vaccine 05/05/2024
Past Problem Onset Clinical Status Verification Status Severity Appendicitis November 11 2023 20:00
Pregnancy confirmed 12/06/2024. Estimated Date of Delivery 15/03/2025.
Social History Observation Value Date Status Tobacco smoking status Never smoker Oct 19 2022 20:00 final Alcoholic drinks per day 1 drink Jun 21 2023 20:00 final
Relevant diagnostic tests/laboratory data note
Test Name Test Result Date Urine M/C/S - pH 7 05/11/2024 Urine M/C/S - Protein Positive 05/11/2024 Urine M/C/S - Blood Positive 05/11/2024 Urine M/C/S - Glucose Positive 05/11/2024 Urine M/C/S - Leucocytes 370 x 10^6/L (<10) 05/11/2024 Urine M/C/S - Erythrocytes 150 x 10^6/L (<10) 05/11/2024 Urine M/C/S - Epithelial cells Nil 05/11/2024 Urine M/C/S - Culture Org 1: Escherichia coli > 10^8 Organisms/mL 05/11/2024 Urine M/C/S - Antimicrobial susceptibility Org 1 Amp/Amoxycillin: Susceptible Amox/clav. acid: Susceptible Cephalexin: Susceptible Trimethoprim: Susceptible Nitrofurantoin: Susceptible Gentamicin: Susceptible Norfloxacin: Susceptible 05/11/2024 Full Blood Count - Haemoglobin 8 g/dL (12-16) 12/06/2024 Full Blood Count - Haematocrit 0.37 L/L (0.37-0.51) 12/06/2024 Full Blood Count - White Blood Cell Count 8 x 10^9/L (4.0-11.0) 12/06/2024 Full Blood Count - Platelets 250 x 10^9/L (150-400) 12/06/2024 Full Blood Count - MCV 85 fL (80-100) 12/06/2024 HCG 16000 IU/L 12/06/2024
Vital Sign Value Date Status Body weight 65 kg Apr 10 2024 05:58 final Body mass index (BMI) [Ratio] 24.56 kg/m2 Apr 10 2024 05:58 final Blood pressure panel with all children optional 140/80 mmHg Aug 30 2024 04:32 final
Generated Narrative: Patient d174bd1a-b368-41e6-83a2-af77f2b3c60f Profile: INPS Patient ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) Contact Detail ph: 0270108012(Home) ph: 0491571804(Mobile) 139 Jungle Lane Noida UP IN
Generated Narrative: Organization 7a17027f-acc0-4d77-bf84-c0dad8f7c881 Profile: INPS Organization identifier: Provider number/4567878 type: Healthcare Provider name: Fertility Clinic telecom: ph: 0255506323(Work) address: 158 Nagar Noida UP partOf: Organization Fertility Clinic Chain
Generated Narrative: Organization 8f8635dc-694e-408f-8ffe-1610d50f9823 Profile: INPS Organization identifier: Provider number/4567879 type: Healthcare Provider name: Fertility Clinic Chain telecom: ph: 0255506327(Work), info@fertility.clinic.chain.in address: 81 Nagar Noida UP
Generated Narrative: PractitionerRole 94d12c8d-a3df-47a7-a0bb-0f29d64bafe2 Profile: INPS PractitionerRole practitioner: Practitioner Dr. DEF code: Doctor
Generated Narrative: Practitioner 816cf057-b736-4e08-baed-cc21e081b784 version: 1; Last updated: 2019-05-29 14:58:58+0530 Profile: INPS Practitioner identifier: Medical License number/21-1521-3828-3227 name: Dr. DEF
Generated Narrative: AllergyIntolerance 9838cf73-c30d-4aa5-8ed8-36a079060b81 Profile: INPS AllergyTolerance clinicalStatus: Active verificationStatus: Unconfirmed code: Prawns patient: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) onset: 2024-11-02 18:50:00+1100 recordedDate: 2024-11-04 note: Pt stated had prawns with dinner and noticed itchy throat, never experienced this before Reactions - Manifestation Severity * Itchy throat Mild
Pt stated had prawns with dinner and noticed itchy throat, never experienced this before
Generated Narrative: Condition 8039e4a7-d459-454c-92a5-6c17ca2a824b Profile: INPS Condition clinicalStatus: Active code: Anaemia subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) asserter: Practitioner Dr. DEF
Generated Narrative: Condition f8ab8ac1-56d1-4239-8303-dc70c1a3d0e1 Profile: INPS Condition clinicalStatus: Active verificationStatus: Confirmed severity: Moderate code: Urinary tract infection (UTI) subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
Generated Narrative: MedicationStatement c3d31980-2a88-45b6-a7af-3fe8d32cc6fa Profile: INPS MedicationStatement status: Stopped medication: Iron and Folic Acid supplements subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024 --> (ongoing) dateAsserted: 2024-10-24 reasonReference: Condition Anaemia Dosages - Text * 2 tablets one in morning and one in evening
2 tablets one in morning and one in evening
Generated Narrative: MedicationStatement b8dac343-16d7-49bf-ac36-b15e6726c343 Profile: INPS MedicationStatement status: Active medication: Prenatal vitamins subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024 --> (ongoing) dateAsserted: 2024-10-24 reasonCode: Pregnancy Dosages - Text Route * 1 tablet daily Oral route
Generated Narrative: MedicationStatement b8e4d4a8-2c18-4f03-88dc-06f5f44f8058 Profile: INPS MedicationStatement status: Active medication: Nitrofurantoin Capsule subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-04 --> (ongoing) dateAsserted: 2024-11-04 reasonReference: Condition Urinary tract infection Dosages - Text Timing Route * 100mg 6-hourly for 5 days Once per 6 hours Oral route
Generated Narrative: Immunization 17b5a6d7-307b-4726-8c8c-0031e61582ce Profile: INPS Immunization status: Completed vaccineCode: Diphtheria + tetanus + pertussis 5 component adolescent/adult vaccine injection, 0.5 mL syringe patient: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) occurrence: 2024-10-05 Performers - Actor * Organization Fertility Clinic
Diphtheria + tetanus + pertussis 5 component adolescent/adult vaccine injection, 0.5 mL syringe
Generated Narrative: Immunization 14e8b0d8-b4e4-4f8e-b263-ef385787453b Profile: INPS Immunization status: Completed vaccineCode: Influenza Vaccine patient: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) occurrence: 2024-07-05 Performers - Actor * Organization Fertility Clinic
Generated Narrative: Observation b0187efd-5f9b-474d-87bc-efebf877449a Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: ABO group [Type] in Blood subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2023-10-31 15:06:00+0000 performer: PractitionerRole Clinical pathologist value: Blood group A
Generated Narrative: Observation f40b9e26-93b4-462b-8811-bdd6943873aa Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Urine M/C/S - pH subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: 7
Generated Narrative: Observation 612b7e6a-c902-45cb-b45c-d1894458a26b Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Urine M/C/S - Protein subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Positive
Protein [Presence] in Urine by Test strip
Generated Narrative: Observation 15bd8c0c-fa53-4f5b-994b-487c7db3dc78 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Urine M/C/S - Blood subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Positive
Hemoglobin [Presence] in Urine by Test strip
Generated Narrative: Observation 5019909f-097d-4a43-84d9-cc50143b8c82 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Urine M/C/S - Glucose subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Positive
Glucose [Presence] in Urine by Test strip
Generated Narrative: Observation 5d269392-79c1-4129-a142-0cdee6b49ea4 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Urine M/C/S - Leucocytes subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: 370 10*6/L (Details: UCUM code10*6/L = '10*6/L') ReferenceRanges - Text * <10
Generated Narrative: Observation 1eaafcef-7841-42c0-9e29-2fb1af2ca9b4 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Urine M/C/S - Erythrocytes subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: 150 10*6/L (Details: UCUM code10*6/L = '10*6/L') ReferenceRanges - Text * <10
Generated Narrative: Observation ac0edca3-83cf-4291-8795-a07551f1ad9a Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Urine M/C/S - Culture subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Escherichia coli
Generated Narrative: Observation 738cdcb5-679f-4491-8c30-f347735057d0 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Colony count subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: >100000000 /mL (Details: UCUM code/mL = '/mL')
Generated Narrative: Observation 92a88264-3979-4dcc-92df-47f4eaa9c4ce Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Amp/Amoxycillin subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Susceptible
Generated Narrative: Observation 4e26d725-1f9b-4054-ae3f-e9053e31f68d Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Amox/clav. acid subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Susceptible
Amoxicillin+Clavulanate [Susceptibility]
Generated Narrative: Observation e292aa91-87ab-4539-b854-9e889f7f3dea Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Cephalexin subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Susceptible
Generated Narrative: Observation 98a8ec51-1547-4341-a1e0-c467e68ba5e3 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Trimethoprim subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Susceptible
Generated Narrative: Observation 0aa8fc17-add4-48ae-bffb-5d27efbf55e2 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Nitrofurantoin subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Susceptible
Generated Narrative: Observation d0eda8ff-6fcd-44cc-8b46-342e4572fa60 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Gentamicin subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Susceptible
Generated Narrative: Observation a0e482c2-8642-4188-9d82-35aad634ef4f Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Norfloxacin subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-11-05 performer: PractitionerRole Clinical pathologist value: Susceptible
Generated Narrative: Observation 86f47d61-0891-4bd2-ab89-08cb886bd06f Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Full Blood Count - Haemoglobin subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-06-12 performer: PractitionerRole Clinical pathologist value: 8 g/dL (Details: UCUM codeg/dL = 'g/dL') ReferenceRanges - Text * 12-16
Generated Narrative: Observation 7e5288c6-f662-4d8d-86ec-dc1651997387 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Full Blood Count - Haematocrit subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-06-12 performer: PractitionerRole Clinical pathologist value: 0.37 L/L (Details: UCUM codeL/L = 'L/L') ReferenceRanges - Text * 0.37-0.51
Hematocrit [Volume Fraction] of Blood by Automated count
Generated Narrative: Observation 0b1e50b3-d39c-4acc-b08d-913f13c17974 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Full Blood Count - White Blood Cell Count subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-06-12 performer: PractitionerRole Clinical pathologist value: 8 10*9/L (Details: UCUM code10*9/L = '10*9/L') ReferenceRanges - Text * 4.0-11.0
Leukocytes [#/volume] in Blood by Automated count
Full Blood Count - White Blood Cell Count
Generated Narrative: Observation fae6e145-5fa6-44bd-9075-5176d72aff78 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Full Blood Count - Platelets subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-06-12 performer: PractitionerRole Clinical pathologist value: 250 10*9/L (Details: UCUM code10*9/L = '10*9/L') ReferenceRanges - Text * 150-400
Platelets [#/volume] in Blood by Automated count
Generated Narrative: Observation 7bc34791-57e0-4ef6-b661-58f8e7a7e457 Profile: INPS Observation Results - Laboratory/Pathology status: Final category: Laboratory code: Full Blood Count - MCV subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-06-12 performer: PractitionerRole Clinical pathologist value: 85 fL (Details: UCUM codefL = 'fL') ReferenceRanges - Text * 80-100
MCV [Entitic mean volume] in Red Blood Cells by Automated count
Generated Narrative: Observation 36ff59b8-d5a7-438e-b8c6-cd54af10a4af Profile: ObservationBodyWeight status: Final category: Vital Signs code: Body weight subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-04-10 09:58:00+0000 performer: PractitionerRole Doctor value: 143.3 lbs (Details: UCUM code[lb_av] = '[lb_av]')
Generated Narrative: Observation 96e33a60-dbd8-47ce-b613-be954243939e Profile: ObservationBMI status: Final category: Vital Signs code: Body mass index (BMI) [Ratio] subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-04-10 09:58:00+0000 performer: PractitionerRole Doctor value: 24.56 kg/m2 (Details: UCUM codekg/m2 = 'kg/m2')
Generated Narrative: Observation 4ea539e1-fff9-4f56-964f-650d9e69ce58 Profile: ObservationBP status: Final category: Vital Signs code: Blood pressure panel with all children optional subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-08-30 08:32:00+0000 performer: PractitionerRole Doctor component code: Systolic blood pressure value: 85 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') interpretation: Normal component code: Diastolic blood pressure value: 50 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') interpretation: Below low normal
Blood pressure panel with all children optional
Generated Narrative: Observation 9f906425-8c18-4580-ab30-61a56d7f4c05 Profile: INPS Observation Social Tobacco Use status: Final category: Social History code: Tobacco smoking status subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2022-10-20 performer: PractitionerRole Doctor value: Never smoker
Generated Narrative: Observation e2e3f8aa-df2a-4357-b01f-a9fba6bb9b41 Profile: INPS Observation Social Alcohol Use status: Final category: Social History code: Alcoholic drinks per day subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2016-06-22 performer: PractitionerRole Doctor value: 1 d (Details: UCUM coded = 'd')
Generated Narrative: PractitionerRole 75ed6f24-9a7e-4568-9c05-91b6d4786743 Profile: INPS PractitionerRole code: Clinical pathologist
Generated Narrative: Condition 77efacd9-b5a6-4b35-9764-269017ea7567 Profile: INPS Condition clinicalStatus: Resolved verificationStatus: Confirmed code: Appendicitis subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) onset: 2023-11-25 asserter: Practitioner Dr. DEF
Generated Narrative: Observation f241ac65-5eab-49a0-8b92-7fb263274110 Profile: INPS Observation Pregnancy Status status: Final code: Pregnancy status subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-06-12 performer: Practitioner Dr. DEF value: Pregnant hasMember: Observation Delivery date Estimated
Generated Narrative: Observation b29e71a6-6dd3-4f9d-bb21-2afb9e2b566c Profile: INPS Observation Pregnancy Expected Delivery Date status: Final category: Imaging code: Delivery date Estimated subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255) effective: 2024-06-12 value: 2025-03-15