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

Patient
Name: Montessori, Eva
DOB: 23-JAN-1972 (Age: 54)
Gender: female
ID: 4182-005348-0 (ECI)
Author
Pasolini, Niccolò
Patient summary Document
European Patient Summary
Report Date: 15-SEP-2024

Problem list

No known problems or disabilities

Medication list

Medication Since Form Dosage Reason
120 ACTUAT fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler [Flovent] 2024-09-15 - 110 mcg, 2 actuations twice daily Childhood asthma
Albuterol (as albuterol sulfate) 830 microgram/mL solution for inhalation 2024-09-15 - 2.5 mg (3 mL of 830 microgram/mL solution) via nebulizer every 4 to 6 hours as needed Childhood asthma
Diphenhydramine hydrochloride 25 mg oral tablet 1974-05-15 - 1 tablet (25 mg) every 6 hours as needed -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 15-Sep-2024
SARS-CoV-2 mRNA vaccine 02-May-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 23-Aug-2020
Live attenuated Human alphaherpesvirus 3 only vaccine product 21-Jul-2019

Procedure History list

Procedure Date Reason
Medication reconciliation 14-Jul-2019 -
Assessment of health and social care needs 14-Jul-2019 -
Assessment of anxiety 14-Jul-2019 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 14-Jul-2019 -
Assessment of substance use 14-Jul-2019 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
Mold 1969-08-08 active environment
Eggs (edible) 1969-08-08 active food Wheal (finding)
Grass pollen 1969-08-08 active environment
House dust mite 1969-08-08 active environment
Animal dander 1969-08-08 active environment Rhinoconjunctivitis (disorder)<br> </br>Cough (finding)
Allergy to drug 1969-08-08 active environment
Tree pollen 1969-08-08 active environment

Care Plan

Active Planned Care / Goals Start Date Reason
Diabetes self management plan 23-Aug-2020 Prediabetes (finding)
  • Achieve and maintain HbA1c below prediabetes threshold through lifestyle changes
Asthma self management 29-Sep-1971 Childhood asthma (disorder)
  • Patient will demonstrate correct inhaler technique and adhere to asthma action plan to reduce frequency of asthma exacerbations.
Self-care interventions 24-Jul-1969 -

Vital Signs

Vital Signs 2024-09-15 2023-09-10
Body Height 163.5 cm 163.5 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 1 {score} 1 {score}
Body Weight 82 kg 82 kg
Body mass index (BMI) [Ratio] 30.7 kg/m2 30.7 kg/m2
Heart rate 65 /min 65 /min
Respiratory rate 15 /min 14 /min
Blood pressure panel with all children optional 77 mm[Hg] 82 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 15-SEP-2024 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 6.3 H 4.0 - 5.6 %
Glucose [Mass/volume] in Blood 90.5 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 11.1 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 0.8 0.5 - 1.1 mg/dL
Calcium [Mass/volume] in Blood 10.1 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 140.1 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.2 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 103.6 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 26.8 22 - 29 mmol/L

Device Use

Device Date (since)
Blood glucose meter (physical object) 23-Aug-2020