Visualize HL7 Example and Test Instances (vi7eti), pronounced /viːˈsɛtiː/
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European Patient Summary

Patient
Name: Roche, Laetitia
DOB: 29-APR-1953 (Age: 72)
Gender: female
ID: 8600-084054-5 (ECI)
Author
Gilbert, Tristan
Patient summary Document
European Patient Summary
Report Date: 24-JUL-2024

Problem list

Condition Onset Date / Period Status
Ischemic heart disease 28-May-2014 active
Malignant neoplasm of breast 26-Apr-2011 active
Essential hypertension 05-Feb-1997 active
Metabolic syndrome X 05-Feb-1997 active
Anemia 07-Jun-1989 active
Gout 08-Aug-1985 active
Sepsis 28-Jan-1984 active
Chronic sinusitis 05-Oct-1971 active
Recurrent urinary tract infection 29-Apr-1971 active
Injury of knee 11-Nov-2024 - 04-Jan-2025 inactive
Injury of medial collateral ligament of knee 11-Nov-2024 - 04-Jan-2025 inactive
Sprain of ankle 23-Aug-2022 - 16-Sep-2022 inactive
Viral sinusitis 22-Dec-2021 - 06-Jan-2022 inactive
Fracture of forearm 19-Sep-2021 - 22-Oct-2021 inactive
Fracture of bone 19-Sep-2021 - 22-Oct-2021 inactive
Viral sinusitis 24-Nov-2020 - 21-Dec-2020 inactive

Medication list

Medication Since Form Dosage Reason
Hydrochlorothiazide 25 mg oral tablet 2024-07-24 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2024-07-24 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet 2014-06-04 - 1 tablet (75 mg) once daily -
Simvastatin 20 mg oral tablet 2014-06-04 - 1 tablet (20 mg) by mouth once daily -
Nitroglycerin 400 microgram/actuation sublingual spray 2014-06-04 - 400 micrograms (1 spray) under the tongue as needed for chest pain, repeat every 5 minutes if needed, up to 3 sprays in 15 minutes -
Metoprolol tartrate (as metoprolol succinate) 100 mg prolonged-release oral tablet 2014-06-04 - 1 tablet (100 mg) once daily -
Ferrous sulfate 325 mg prolonged-release oral tablet 1989-06-14 - 1 tablet (325 mg) by mouth once daily -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 24-Jul-2024
SARS-CoV-2 mRNA vaccine 31-Mar-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 01-Jul-2020

Procedure History list

Procedure Date Reason
Pre-discharge assessment 03-Dec-2024 -
Discharge from hospital 03-Dec-2024 -
Professional / ancillary services care 02-Dec-2024 -
Nursing care/supplementary surveillance 02-Dec-2024 -
Occupational therapy 25-Nov-2024 -
Physical therapy procedure 25-Nov-2024 -
History AND physical examination 22-Nov-2024 -
Postoperative care 22-Nov-2024 Injury of medial collateral ligament of knee (disorder)
Initial patient assessment 22-Nov-2024 -
Development of individualized plan of care 22-Nov-2024 -
Surgical manipulation of joint of knee 18-Nov-2024 Injury of medial collateral ligament of knee (disorder)
Plain X-ray of knee region 11-Nov-2024 -
Patient discharge 26-Jun-2024 -
Hospice care 25-Jun-2024 -
Notifications 05-Jun-2024 -
Certification procedure 05-Jun-2024 -
Bone immobilization 19-Sep-2021 Fracture of forearm (disorder)
Bone density scan 19-Sep-2021 Fracture of forearm (disorder)
Plain X-ray of humerus 19-Sep-2021 -

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Lifestyle education regarding hypertension 05-Feb-1997 Essential hypertension (disorder)
  • Patient will receive education on lifestyle changes (diet, exercise, sodium reduction, weight management) to support blood pressure control.
Diabetes self management plan 20-Aug-1986 Prediabetes (finding)
  • Patient will attend diabetes self-management education sessions to improve understanding of prediabetes and lifestyle modifications.
  • Maintain fasting plasma glucose within recommended range for prediabetes.
  • Maintain HbA1c below threshold for diabetes diagnosis.
Musculoskeletal care 08-Aug-1985 -
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2024-07-24 2023-07-19
Body Height 143.2 cm 143.2 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 0 {score}
Body Weight 56.7 kg 56.7 kg
Body mass index (BMI) [Ratio] 27.7 kg/m2 27.7 kg/m2
Heart rate 97 /min 99 /min
Respiratory rate 15 /min 14 /min
Blood pressure panel with all children optional 71 mm[Hg] 76 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 24-JUL-2024 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 6.1 H 4.0 - 5.6 %
Glucose [Mass/volume] in Blood 67.5 L 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 15.0 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 0.5 L 0.6 - 1.1 mg/dL
Calcium [Mass/volume] in Blood 9.8 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 140.8 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 3.8 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 110.3 H 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 21.3 L 22 - 29 mmol/L

Device Use

Device Date (since)
Blood glucose meter (physical object) 20-Aug-1986
Home nebulizer (physical object) 05-Oct-1971