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

Patient
Name: Bobrowicz, Angelika
DOB: 26-AUG-1952 (Age: 73)
Gender: female
ID: 5772-615752-2 (ECI)
Author
dr Tylka, Aniela
Patient summary Document
European Patient Summary
Report Date: 20-SEP-2024

Problem list

Condition Onset Date / Period Status
Disorder of kidney due to diabetes mellitus 01-Jul-2022 active
Chronic kidney disease stage 1 01-Jul-2022 active
Metabolic syndrome X 01-Mar-1991 active
Anemia 31-Jan-1986 active
Essential hypertension 25-Jan-1985 active
Sepsis 05-Mar-1978 active
Acute viral pharyngitis 06-Mar-2019 - 16-Mar-2019 inactive
Acute viral pharyngitis 25-Apr-2018 - 06-May-2018 inactive
Viral sinusitis 14-Nov-2016 - 27-Nov-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 2024-09-20 - Inject 20 units (14 units isophane insulin 70/30 and 6 units regular insulin 70/30) subcutaneously twice daily before breakfast and dinner Prediabetes
Hydrochlorothiazide 25 mg oral tablet 2024-09-20 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2024-09-20 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Acetaminophen 300 mg and hydrocodone bitartrate 5 mg oral tablet 2024-09-20 - 1 tablet (300 mg/5 mg) by mouth every 4 to 6 hours as needed for pain -
Acetaminophen 325 mg and oxycodone hydrochloride 10 mg oral tablet 2024-09-20 - 1 tablet (acetaminophen 325 mg and oxycodone hydrochloride 10 mg) every 6 hours as needed -
Hydrocodone bitartrate 10 mg and ibuprofen 200 mg oral tablet 2024-09-20 - 1 tablet (10 mg/200 mg) by mouth every 6 hours as needed -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 06-Sep-2024
Clostridium tetani toxoid antigen adsorbed only vaccine product 01-Jul-2022
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 28-Jul-2017
Streptococcus pneumoniae Danish serotype 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F, capsular polysaccharide conjugated antigens only vaccine product 22-Jul-2016

Procedure History list

No known procedures

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Therapy 17-Mar-2014 -
Lifestyle education regarding hypertension 25-Jan-1985 Essential hypertension (disorder)
  • Patient will implement lifestyle changes to help lower blood pressure, including dietary modifications, increased physical activity, and sodium reduction.
Diabetes self management plan 16-Jan-1976 Prediabetes (finding)
  • Maintain hemoglobin A1c below 6.5% through diabetes self-management.
  • Achieve and maintain a healthy body weight as part of diabetes self-management.
  • Maintain blood pressure below 130/80 mmHg as part of diabetes self-management.
  • Engage in at least 150 minutes of moderate-intensity physical activity per week.
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2024-09-20 2024-09-06
Body Height 148.2 cm 148.2 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 1 {score} 2 {score}
Body Weight 60.5 kg 60.5 kg
Body mass index (BMI) [Ratio] 27.6 kg/m2 27.6 kg/m2
Heart rate 83 /min 79 /min
Respiratory rate 13 /min 13 /min
Blood pressure panel with all children optional 84 mm[Hg] 84 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 20-SEP-2024 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 64.8 L 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 14.1 7 - 20 mg/dL
Creatinine [Mass/volume] in Serum or Plasma 1.6 H 0.5 - 1.1 mg/dL
Calcium [Mass/volume] in Serum or Plasma 9.8 8.6 - 10.3 mg/dL
Sodium [Moles/volume] in Serum or Plasma 142.9 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 4.2 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Serum or Plasma 105.7 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma 20.1 L 22 - 29 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 2.2 H 0 - 0.8 mg/dL
Glucose [Presence] in Urine by Test strip Urine glucose test = ++
Bilirubin.total [Mass/volume] in Urine by Test strip 0.6 0 - 4 mg/dL
Bilirubin.total [Presence] in Urine by Test strip Finding of bilirubin in urine
Ketones [Mass/volume] in Urine by Test strip 17.8 H 0 - 4 mg/dL
Ketones [Presence] in Urine by Test strip Urine ketone test = trace
Specific gravity of Urine by Test strip 1.0 L 1.005 - 1.030 {nominal}
pH of Urine by Test strip 5.4 5.0 - 8.0 pH
Protein [Mass/volume] in Urine by Test strip 58.9 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 3.2 L 4.0 - 5.6 %
Glucose [Mass/volume] in Blood 64.8 L 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 14.1 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 0.6 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.8 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 142.9 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.2 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 105.7 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 20.1 L 22 - 29 mmol/L

Device Use

Device Date (since)
Blood glucose meter (physical object) 16-Jan-1976