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

Patient
Name: Quesada, Anastasia
DOB: 09-APR-1955 (Age: 70)
Gender: female
ID: 7881-246905-0 (ECI)
Author
dr Uribe, Eufemia
Patient summary Document
European Patient Summary
Report Date: 02-AUG-2024

Problem list

Condition Onset Date / Period Status
Acute ST segment elevation myocardial infarction 19-Jun-2022 active
Osteoporosis 08-Apr-2022 active
Osteoarthritis of hip 09-Jun-2005 active
Chronic sinusitis 08-Jan-1962 active
Fracture of forearm 28-Dec-2022 - 07-May-2023 inactive
Fracture of bone 28-Dec-2022 - 07-May-2023 inactive
Osteoporotic fracture 28-Dec-2022 - 07-May-2023 inactive
Myocardial infarction 19-Jun-2022 - 19-Jun-2022 inactive
Acute viral pharyngitis 31-Mar-2022 - 12-Apr-2022 inactive
COVID-19 02-Feb-2021 - 02-Mar-2021 inactive
Viral sinusitis 17-Sep-2017 - 10-Oct-2017 inactive
Fracture of clavicle 15-Jul-2016 - 05-Nov-2016 inactive
Fracture of bone 15-Jul-2016 - 05-Nov-2016 inactive
Acute bronchitis 28-Jun-2016 - 15-Jul-2016 inactive

Medication list

Medication Since Form Dosage Reason
Alendronic acid (as alendronate sodium) 10 mg oral tablet 2024-08-02 - 1 tablet (10 mg) once daily Osteoporosis (disorder)
Aspirin 81 mg gastro-resistant oral tablet 2022-06-19 - 1 tablet (81 mg) by mouth once daily -
Lisinopril 2.5 mg oral tablet 2022-06-19 - 1 tablet (2.5 mg) once daily -
Atorvastatin (as atorvastatin calcium) 20 mg oral tablet 2022-06-19 - 1 tablet (20 mg) by mouth once daily -
Prasugrel (as prasugrel hydrochloride) 10 mg oral tablet 2022-06-19 - 10 mg once daily -
Metoprolol tartrate (as metoprolol succinate) 100 mg prolonged-release oral tablet 2022-06-19 - 1 tablet (100 mg) once daily -
Naproxen sodium 220 mg oral capsule 2005-06-09 - 1 capsule (220 mg) by mouth every 12 hours as needed Osteoarthritis of hip
Ferrous sulfate 325 mg prolonged-release oral tablet 1986-06-20 - 1 tablet (325 mg) by mouth once daily -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 02-Aug-2024
Clostridium tetani toxoid antigen adsorbed only vaccine product 28-Jul-2023
SARS-CoV-2 mRNA vaccine 09-Apr-2021
Streptococcus pneumoniae Danish serotype 1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F, 33F capsular polysaccharide antigens conjugated only vaccine product 29-Jun-2018
Streptococcus pneumoniae Danish serotype 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F, capsular polysaccharide conjugated antigens only vaccine product 23-Jun-2017

Procedure History list

Procedure Date Reason
Pre-discharge assessment 08-Jan-2023 -
Discharge from hospital 08-Jan-2023 -
Nursing care/supplementary surveillance 07-Jan-2023 -
Occupational therapy 04-Jan-2023 -
Professional / ancillary services care 02-Jan-2023 -
History AND physical examination 28-Dec-2022 -
Bone immobilization 28-Dec-2022 Fracture of forearm (disorder)
Initial patient assessment 28-Dec-2022 -
Development of individualized plan of care 28-Dec-2022 -
Plain X-ray of humerus 28-Dec-2022 -
Laboratory test 19-Jun-2022 -
Electrocardiographic procedure 19-Jun-2022 -
Angiography of coronary artery 19-Jun-2022 -
Diagnostic assessment 19-Jun-2022 -
Oxygen administration by mask 19-Jun-2022 -
Plain X-ray of chest 19-Jun-2022 -
Percutaneous coronary intervention 19-Jun-2022 Acute ST segment elevation myocardial infarction (disorder)
Transthoracic echocardiography 19-Jun-2022 -
Consultation for treatment 19-Jun-2022 -
Assessment of cardiac status using monitoring device 19-Jun-2022 -
Plain X-ray of clavicle 15-Jul-2016 -
Admission to orthopedic department 15-Jul-2016 Fracture of clavicle (disorder)
Bone density scan 15-Jul-2016 Fracture of clavicle (disorder)

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Discharge care plan 19-Jun-2022 -
Musculoskeletal care 09-Jun-2005 Osteoarthritis of hip (disorder)
  • Patient will report a reduction in hip pain severity during daily activities.
  • Patient will increase ability to walk and perform activities of daily living without significant limitation.
  • Patient will be able to walk at least 30 minutes per day, 5 days per week.
Diabetes self management plan 01-Jun-2001 Prediabetes (finding)
  • Patient will implement lifestyle changes to reduce risk of progression to diabetes, including dietary modifications, increased physical activity, and regular blood glucose monitoring.
Routine antenatal care 20-Jun-1986 -
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2024-08-02 2023-07-28
Body Height 163 cm 163 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 4 {score} 3 {score}
Body Weight 73.5 kg 73.5 kg
Body mass index (BMI) [Ratio] 27.7 kg/m2 27.7 kg/m2
Heart rate 88 /min 77 /min
Respiratory rate 16 /min 14 /min
Blood pressure panel with all children optional 71 mm[Hg] 71 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 02-AUG-2024 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 6.1 H 4.8 - 5.9 %
Glucose [Mass/volume] in Blood 86.6 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 8.6 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 0.6 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 8.8 8.6 - 10.3 mg/dL
Sodium [Moles/volume] in Blood 141.7 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.0 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 110.7 H 98 - 110 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 28.7 22 - 29 mmol/L
Leukocytes [#/volume] in Blood by Automated count 4.5 4.0 - 11.0 10*3/uL
Erythrocytes [#/volume] in Blood by Automated count 4.9 3.8 - 5.1 10*6/uL
Hemoglobin [Mass/volume] in Blood 17.0 H 12 - 16 g/dL
Hematocrit [Volume Fraction] of Blood by Automated count 49.3 H 36 - 46 %
MCV [Entitic mean volume] in Red Blood Cells by Automated count 82.8 80 - 100 fL
MCH [Entitic mass] by Automated count 33.0 27 - 33 pg
MCHC [Entitic Mass/volume] in Red Blood Cells by Automated count 34.0 32 - 36 g/dL
Erythrocyte distribution width [Entitic volume] by Automated count 42.3 36 - 48 fL
Platelets [#/volume] in Blood by Automated count 198.9 150 - 450 10*3/uL
Platelet distribution width [Entitic volume] in Blood by Automated count 225.5 H 9.4 - 12.3 fL
Platelet [Entitic mean volume] in Blood by Automated count 11.2 7.2 - 12.2 fL

Device Use

Device Date (since)
Walking frame (physical object) 09-Jun-2005
Blood glucose meter (physical object) 01-Jun-2001
Home nebulizer (physical object) 08-Jan-1962