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European Patient Summary

Patient
Name: Hayward, Tom
DOB: 07-APR-1975 (Age: 50)
Gender: male
ID: 3376-612163-7 (ECI)
Author
Evans, Anthony
Patient summary Document
European Patient Summary
Report Date: 17-JUL-2025

Problem list

Condition Onset Date / Period Status
Chronic kidney disease stage 4 22-Dec-2022 active
Chronic kidney disease stage 3 16-Jul-2020 active
Proteinuria due to type 2 diabetes mellitus 16-Jul-2020 active
Ischemic heart disease 17-Jan-2019 active
Hyperlipidemia 23-Nov-2017 active
Chronic kidney disease stage 2 09-Jul-2009 active
Microalbuminuria due to type 2 diabetes mellitus 09-Jul-2009 active
Disorder of kidney due to diabetes mellitus 25-Jan-2007 active
Chronic kidney disease stage 1 25-Jan-2007 active
Nonproliferative retinopathy due to type 2 diabetes mellitus 29-Dec-2005 active
Retinopathy due to type 2 diabetes mellitus 18-Dec-2003 active
Anemia 06-Dec-2001 active
Hyperglycemia 30-Nov-2000 active
Metabolic syndrome X 30-Nov-2000 active
Hypertriglyceridemia 30-Nov-2000 active
Type 2 diabetes mellitus 25-Nov-1999 active
Essential hypertension 25-Nov-1999 active
Acute infective cystitis 25-Jun-2025 - 05-Jul-2025 inactive
Acute viral pharyngitis 04-Jan-2024 - 13-Jan-2024 inactive
Acute viral pharyngitis 19-Apr-2016 - 29-Apr-2016 inactive
Concussion with no loss of consciousness 10-Mar-2016 - 12-May-2016 inactive
Concussion injury of brain 10-Mar-2016 - 12-May-2016 inactive

Medication list

Medication Since Form Dosage Reason
Human isophane insulin 70 unit/mL and recombinant human regular insulin 30 unit/mL solution for injection 2025-07-17 - Inject 10 units subcutaneously before breakfast and 10 units before dinner (strength: 70 units/mL isophane insulin and 30 units/mL regular insulin) Diabetes mellitus type 2 (disorder)
Hydrochlorothiazide 25 mg oral tablet 2025-07-17 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2025-07-17 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Metformin hydrochloride 500 mg prolonged-release oral tablet 2025-07-17 - 1 tablet (500 mg) once daily Diabetes mellitus type 2 (disorder)
Simvastatin 10 mg oral tablet 2025-01-30 - 1 tablet (10 mg) by mouth once daily Hyperlipidemia
Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet 2019-01-24 - 1 tablet (75 mg) once daily -
Simvastatin 20 mg oral tablet 2019-01-24 - 1 tablet (20 mg) by mouth once daily -
Nitroglycerin 400 microgram/actuation sublingual spray 2019-01-24 - 400 micrograms (1 spray) under the tongue as needed for chest pain, may repeat every 5 minutes as needed, up to 3 sprays in 15 minutes -
Metoprolol tartrate (as metoprolol succinate) 100 mg prolonged-release oral tablet 2019-01-24 - 1 tablet (100 mg) once daily -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 20-Mar-2025
Clostridium tetani toxoid antigen adsorbed only vaccine product 22-Sep-2022
Live attenuated Human alphaherpesvirus 3 only vaccine product 31-Mar-2022
SARS-CoV-2 mRNA vaccine 14-Oct-2021

Procedure History list

Procedure Date Reason
Screening for substance abuse 17-Jul-2025 -
Assessment of health and social care needs 17-Jul-2025 -
Assessment of substance use 17-Jul-2025 -
Depression screening 15-May-2025 -
Assessment of anxiety 15-May-2025 -
Depression screening using PHQ-9 (Patient Health Questionnaire 9) score 15-May-2025 -
Screening for domestic abuse 15-May-2025 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 10-Oct-2024 -
Medication reconciliation 20-Jun-2024 -
Postoperative procedure education 14-May-2019 History of coronary artery bypass grafting (situation)
Stair-climbing test 14-May-2019 History of coronary artery bypass grafting (situation)
Walking exercise test 14-May-2019 History of coronary artery bypass grafting (situation)
Discharge to ward 14-May-2019 -
Discharge from hospital 14-May-2019 History of coronary artery bypass grafting (situation)
Electrocardiographic procedure 13-May-2019 -
Transfusion of packed red blood cells 13-May-2019 -
Plain X-ray of chest 13-May-2019 -
Removal of endotracheal tube 10-May-2019 -

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Dialysis care plan 21-Dec-2023 -
Hyperlipidemia clinical management plan 14-Dec-2017 Hyperlipidemia (disorder)
  • Achieve LDL cholesterol below 1.8 mmol/L in patient with ischemic heart disease and diabetes.
  • Achieve fasting triglycerides below 1.7 mmol/L.
  • Maintain HDL cholesterol above 1.0 mmol/L.
  • Achieve total cholesterol below 4.0 mmol/L.
Lifestyle education regarding hypertension 25-Nov-1999 Essential hypertension (disorder)
  • Patient will achieve and maintain blood pressure below 130/80 mmHg through lifestyle modifications.
  • Patient will implement recommended lifestyle changes (diet, exercise, sodium reduction, weight management) to support blood pressure control.
Diabetes self management plan 25-Nov-1999 Diabetes mellitus type 2 (disorder)
  • Maintain HbA1c at or below individualized target to reduce risk of microvascular and macrovascular complications.
  • Maintain blood pressure below 130/80 mmHg to reduce risk of cardiovascular and renal complications.
  • Maintain LDL cholesterol below 70 mg/dL to reduce risk of atherosclerotic cardiovascular disease.
  • Perform self-monitoring of blood glucose as recommended to optimize glycemic control and detect hypoglycemia or hyperglycemia.
  • Implement dietary modifications, increase physical activity, and achieve weight management goals to improve glycemic control and overall health.

Vital Signs

Vital Signs 2025-07-17 2025-07-02
Body Height 164.3 cm -
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 2 {score}
Body Weight 84.5 kg -
Body mass index (BMI) [Ratio] 31.3 kg/m2 -
Heart rate 64 /min -
Respiratory rate 15 /min -
Blood pressure panel with all children optional 85 mm[Hg] -
Weight difference [Mass difference] --pre dialysis - post dialysis - 1 kg

Relevant diagnostic tests/laboratory data

Recent Lab Observations 17-JUL-2025 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 67.8 L 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 19.8 7 - 20 mg/dL
Creatinine [Mass/volume] in Serum or Plasma 2.4 H 0.6 - 1.2 mg/dL
Calcium [Mass/volume] in Serum or Plasma 9.2 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Serum or Plasma 142.2 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 4.5 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Serum or Plasma 106.4 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma 26.0 22 - 32 mmol/L
Appearance of Urine Cloudy urine
Odor of Urine Urine smell ammoniacal
Clarity of Urine Translucent
Color of Urine Brown color
Glucose [Mass/volume] in Urine by Test strip 1.3 0 - 5 mg/dL
Glucose [Presence] in Urine by Test strip Urine glucose test = ++
Bilirubin.total [Mass/volume] in Urine by Test strip 0.3 0 - 1 mg/dL
Bilirubin.total [Presence] in Urine by Test strip Finding of bilirubin in urine
Ketones [Mass/volume] in Urine by Test strip 14.9 0 - 20 mg/dL
Ketones [Presence] in Urine by Test strip Urine ketone test negative
Specific gravity of Urine by Test strip 1.0 L 1.005 - 1.030 {nominal}
pH of Urine by Test strip 6.0 5.0 - 8.0 pH
Protein [Mass/volume] in Urine by Test strip 289.8 H 0 - 20 mg/dL
Protein [Presence] in Urine by Test strip Urine protein test = +++
Nitrite [Presence] in Urine by Test strip Urine nitrite negative
Hemoglobin [Presence] in Urine by Test strip Urine blood test = negative
Leukocyte esterase [Presence] in Urine by Test strip Urine leukocyte test negative
Hemoglobin A1c/Hemoglobin.total in Blood 3.3 L 4.0 - 5.6 %
Glucose [Mass/volume] in Blood 67.8 L 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 19.8 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 20.5 H 0.6 - 1.2 mg/dL
Calcium [Mass/volume] in Blood 9.2 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 142.2 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.5 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 106.4 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 26.0 22 - 29 mmol/L
Cholesterol [Mass/volume] in Serum or Plasma 142.6 125 - 200 mg/dL
Triglyceride [Mass/volume] in Serum or Plasma 145.0 0 - 150 mg/dL
Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay 52.6 0 - 100 mg/dL
Cholesterol in HDL [Mass/volume] in Serum or Plasma 61.1 H 40 - 60 mg/dL
Microalbumin/Creatinine [Mass Ratio] in Urine 378.7 H 0 - 30 mg/g

Device Use

Device Date (since)
Blood glucose meter (physical object) 25-Nov-1999