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European Patient Summary

Patient
Name: Berrè, Patrizio
DOB: 21-FEB-1949 (Age: 77)
Gender: male
ID: 3822-672758-4 (ECI)
Author
dr Broschi, Ninetta
Patient summary Document
European Patient Summary
Report Date: 16-JUL-2025

Problem list

Condition Onset Date / Period Status
Ischemic heart disease 03-Jul-2024 active
Hyperlipidemia 24-May-2017 active
Anemia 30-Jul-1997 active
Essential hypertension 29-Oct-1980 active
Viral sinusitis 28-May-2024 - 13-Jun-2024 inactive

Medication list

Medication Since Form Dosage Reason
Simvastatin 10 mg oral tablet 2025-07-15 - 1 tablet (10 mg) by mouth once daily Hyperlipidemia
NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] 2025-07-08 - 2 actuations (180 mcg) every 4 to 6 hours as needed Childhood asthma
Hydrochlorothiazide 25 mg oral tablet 2025-07-08 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2025-07-08 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Budesonide 250 microgram/mL suspension for nebulizer 2025-07-08 - 250 micrograms via nebulizer twice daily Childhood asthma
Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet 2024-07-09 - 1 tablet (75 mg) once daily -
Simvastatin 20 mg oral tablet 2024-07-09 - 1 tablet (20 mg) by mouth once daily -
Nitroglycerin 400 microgram/actuation sublingual spray 2024-07-09 - 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 2024-07-09 - 1 tablet (100 mg) once daily -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 08-Jul-2025
SARS-CoV-2 mRNA vaccine 30-Mar-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 23-May-2017

Procedure History list

Procedure Date Reason
Discharge from hospital 05-Aug-2024 History of coronary artery bypass grafting (situation)
Postoperative procedure education 04-Aug-2024 History of coronary artery bypass grafting (situation)
Stair-climbing test 04-Aug-2024 History of coronary artery bypass grafting (situation)
Walking exercise test 04-Aug-2024 History of coronary artery bypass grafting (situation)
Discharge to ward 04-Aug-2024 -
Electrocardiographic procedure 03-Aug-2024 -
Transfusion of packed red blood cells 03-Aug-2024 -
Plain X-ray of chest 03-Aug-2024 -
Transfusion of fresh frozen plasma 30-Jul-2024 -
Induced cardioplegia 27-Jul-2024 -
Documentation procedure 27-Jul-2024 -
Echocardiography 27-Jul-2024 -
Cannulation 27-Jul-2024 -
Blood group typing 27-Jul-2024 -
Intubation 27-Jul-2024 -
Cardiopulmonary bypass operation 27-Jul-2024 -
Pulmonary catheterization with Swan-Ganz catheter 27-Jul-2024 -
Pre-surgery testing 27-Jul-2024 -
Preparation of patient for procedure 27-Jul-2024 -
Coronary artery bypass graft 27-Jul-2024 Ischemic heart disease (disorder)
Vascular cannula removal 27-Jul-2024 -
Removal of endotracheal tube 27-Jul-2024 -
Placement of aortic cross clamp 27-Jul-2024 -
Removal of aortic cross clamp 27-Jul-2024 -
Median sternotomy 27-Jul-2024 -
Insertion of catheter into artery 27-Jul-2024 -
Administration of anesthesia 27-Jul-2024 -
Scheduling 27-Jul-2024 Abnormal findings diagnostic imaging heart+coronary circulat (finding)
Notification of treatment plan 27-Jul-2024 -

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Hyperlipidemia clinical management plan 14-Jun-2017 Hyperlipidemia (disorder)
  • Achieve LDL cholesterol below 70 mg/dL for secondary prevention in ischemic heart disease.
  • Maintain total cholesterol below 150 mg/dL.
  • Maintain triglycerides below 150 mg/dL.
  • Maintain HDL cholesterol above 40 mg/dL.
Diabetes self management plan 24-Jan-1996 Prediabetes (finding)
  • Maintain hemoglobin A1c below 6.5% through lifestyle modification and self-management.
  • Achieve and maintain a healthy body weight as part of diabetes prevention plan.
  • Maintain blood pressure below 130/80 mmHg as part of cardiovascular risk reduction in prediabetes.
  • Maintain LDL cholesterol below 70 mg/dL to reduce cardiovascular risk.
Lifestyle education regarding hypertension 29-Oct-1980 Essential hypertension (disorder)
  • Patient will receive education on lifestyle changes to help manage blood pressure, including diet, exercise, and sodium reduction.
Asthma self management 29-Apr-1950 Childhood asthma (disorder)
  • Patient will demonstrate understanding of asthma self-management strategies, including inhaler technique, trigger avoidance, and action plan adherence.
  • Patient will report no more than 2 days per week with asthma symptoms.
  • Patient will use rescue inhaler no more than 2 times per week.
  • Patient will have zero asthma-related emergency department visits or hospitalizations in the next 12 months.
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2025-07-08 2024-08-04
Body Height 182.1 cm -
Pain severity - 0-10 verbal numeric rating [Score] - Reported 4 {score} -
Body Weight 92.4 kg -
Body mass index (BMI) [Ratio] 27.9 kg/m2 -
Heart rate 91 /min -
Respiratory rate 14 /min -
Blood pressure panel with all children optional 57 mm[Hg] -
Oxygen saturation in Arterial blood - 97 %

Relevant diagnostic tests/laboratory data

Recent Lab Observations 16-JUL-2025 Reference Range Unit
Glucose [Mass/volume] in Blood 85.4 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 12.7 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 3.2 H 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 10.0 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 143.8 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.0 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 108.2 98 - 110 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 23.5 22 - 29 mmol/L
Protein [Mass/volume] in Serum or Plasma 6.3 L 6.6 - 8.3 g/dL
Albumin [Mass/volume] in Serum or Plasma 4.7 3.5 - 5.5 g/dL
Globulin [Mass/volume] in Serum by calculation 2.4 L 20 - 39 g/L
Bilirubin.total [Mass/volume] in Serum or Plasma 0.4 0.1 - 1.2 mg/dL
Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma 35.4 30 - 120 U/L
Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma 20.6 10 - 40 U/L
Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma 20.3 10 - 40 U/L
Cholesterol [Mass/volume] in Serum or Plasma 208.5 H 125 - 200 mg/dL
Triglyceride [Mass/volume] in Serum or Plasma 169.7 H 0 - 150 mg/dL
Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay 114.7 H 0 - 100 mg/dL
Cholesterol in HDL [Mass/volume] in Serum or Plasma 40.7 40 - 60 mg/dL

Device Use

Device Date (since)
Blood glucose meter (physical object) 23-Jan-1996