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

Patient
Name: Julien, Alexandria
DOB: 22-MAR-1959 (Age: 67)
Gender: female
ID: 1074-205969-3 (ECI)
Author
Maillard, Margot
Patient summary Document
European Patient Summary
Report Date: 20-JAN-2025

Problem list

Condition Onset Date / Period Status
Essential hypertension 01-Oct-2024 active
Metabolic syndrome X 01-Oct-2024 active
Ischemic heart disease 01-Oct-2024 active
Chronic sinusitis 28-May-2018 active
Acute infective cystitis 20-Jan-2025 - 22-Jan-2025 inactive
Sinusitis 02-May-2018 - 06-Aug-2018 inactive
Viral sinusitis 24-May-2016 - 06-Jun-2016 inactive

Medication list

Medication Since Form Dosage Reason
Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet 2024-10-08 - 1 tablet (75 mg) once daily -
Simvastatin 20 mg oral tablet 2024-10-08 - 1 tablet (20 mg) once daily -
Nitroglycerin 400 microgram/actuation sublingual spray 2024-10-08 - 1 spray (400 micrograms) 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 2024-10-08 - 1 tablet (100 mg) once daily -
Lisinopril 10 mg oral tablet 2024-10-01 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 01-Oct-2024
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 26-Sep-2023
Streptococcus pneumoniae Danish serotype 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F, capsular polysaccharide conjugated antigens only vaccine product 20-Sep-2022
SARS-CoV-2 mRNA vaccine 13-Apr-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 10-Jul-2018

Procedure History list

No known procedures

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Lifestyle education regarding hypertension 01-Oct-2024 Essential hypertension (disorder)
  • Patient will demonstrate understanding of lifestyle modifications to manage blood pressure, including diet, exercise, and medication adherence.
Diabetes self management plan 01-Jul-1997 Prediabetes (finding)
  • Patient will verbalize understanding of prediabetes and demonstrate ability to monitor blood glucose, follow dietary recommendations, and engage in regular physical activity.
  • Maintain or reduce HbA1c to below 5.7% to prevent progression to diabetes.
  • Patient will achieve a 5% reduction in body weight to improve metabolic parameters.
  • Maintain blood pressure below 130/80 mmHg as part of diabetes risk reduction.
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2025-02-28 2024-12-30
Blood pressure panel with all children optional 82 mm[Hg] 85 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 20-JAN-2025 Reference Range Unit
Glucose [Mass/volume] in Urine by Test strip 10.8 0 - 15 mg/dL
Ketones [Presence] in Urine by Test strip Urine ketone test negative
Specific gravity of Urine by Test strip 1.0 L 1.005 - 1.030 {nominal}
pH of Urine by Test strip 7.0 4.5 - 8.0 pH
Protein [Mass/volume] in Urine by Test strip 7.4 0 - 20 mg/dL
Nitrite [Presence] in Urine by Test strip Urine nitrite positive
Hemoglobin [Presence] in Urine by Test strip Urine blood test = +
Leukocyte esterase [Presence] in Urine by Test strip Urine leukocyte test
Leukocytes [#/area] in Urine sediment by Microscopy high power field 34.0 H 0 - 5 /[HPF]
Erythrocytes [#/area] in Urine sediment by Microscopy high power field 2.4 0 - 5 /[HPF]
Epithelial cells [#/area] in Urine sediment by Microscopy high power field 2.0 0 - 10 /[HPF]
Casts [Presence] in Urine sediment by Light microscopy Urine microscopy: no casts
Mucus [Presence] in Urine sediment by Light microscopy Mucus in urine
Bacteria [#/area] in Urine sediment by Microscopy high power field Finding of presence of bacteria
Bacteria identified in Urine by Culture

Device Use

Device Date (since)
Home nebulizer (physical object) 28-May-2018
Blood glucose meter (physical object) 01-Jul-1997