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European Patient Summary

Patient
Name: Bauer, Angela
DOB: 08-DEC-1968 (Age: 57)
Gender: female
ID: 9736-451235-6 (ECI)
Author
Dr. Plattner, Carla
Patient summary Document
European Patient Summary
Report Date: 25-APR-2025

Problem list

Condition Onset Date / Period Status
Chronic kidney disease stage 3 12-Nov-2021 active
Proteinuria due to type 2 diabetes mellitus 12-Nov-2021 active
Metabolic syndrome X 04-May-2018 active
Osteoarthritis of hip 02-Dec-2013 active
Chronic kidney disease stage 2 10-Dec-1999 active
Microalbuminuria due to type 2 diabetes mellitus 10-Dec-1999 active
Disorder of kidney due to diabetes mellitus 15-Jan-1999 active
Chronic kidney disease stage 1 15-Jan-1999 active
Essential hypertension 01-Jul-1994 active
Acute bronchitis 03-Jun-2022 - 22-Jun-2022 inactive
Fracture of bone 02-May-2021 - 20-Aug-2021 inactive
Fracture subluxation of wrist 02-May-2021 - 20-Aug-2021 inactive
Acute viral pharyngitis 03-Jul-2020 - 10-Jul-2020 inactive
Viral sinusitis 05-May-2017 - 23-May-2017 inactive
Streptococcal sore throat 02-Dec-2016 - 14-Dec-2016 inactive
Viral sinusitis 02-Dec-2016 - 17-Dec-2016 inactive
Viral sinusitis 01-Apr-2016 - 22-Apr-2016 inactive
Acute bronchitis 20-Jul-2015 - 29-Jul-2015 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 2025-04-25 - Inject 30 units (70/30 insulin) subcutaneously once daily Prediabetes
Hydrochlorothiazide 25 mg oral tablet 2025-04-25 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2025-04-25 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Acetaminophen 300 mg and hydrocodone bitartrate 5 mg oral tablet 2025-04-25 - 1 tablet (300 mg / 5 mg) by mouth every 4 to 6 hours as needed for pain -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 20-Dec-2024
SARS-CoV-2 mRNA vaccine 28-May-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 12-May-2017
Live attenuated Human alphaherpesvirus 3 only vaccine product 28-Oct-2016

Procedure History list

Procedure Date Reason
Depression screening 17-Jun-2022 -
Screening for substance abuse 17-Jun-2022 -
Assessment of health and social care needs 17-Jun-2022 -
Assessment of substance use 17-Jun-2022 -
Medication reconciliation 27-May-2022 -
Screening for domestic abuse 27-May-2022 -
Assessment of anxiety 13-May-2022 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 13-May-2022 -
Bone immobilization 02-May-2021 Fracture subluxation of wrist (disorder)
Bone density scan 02-May-2021 Fracture subluxation of wrist (disorder)
Plain X-ray of wrist region 02-May-2021 -
Depression screening using PHQ-9 (Patient Health Questionnaire 9) score 29-Jul-2016 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
Inadequate digital access affecting health care 2026-03-14 active environment

Care Plan

Active Planned Care / Goals Start Date Reason
Diabetes self management plan 10-Nov-2017 Prediabetes (finding)
  • Maintain or reduce HbA1c to target level as part of diabetes self-management.
  • Achieve and maintain a healthy body weight to support diabetes self-management.
  • Maintain blood pressure within target range to support diabetes self-management.
  • Engage in at least 150 minutes of moderate-intensity physical activity per week as part of diabetes self-management.
Musculoskeletal care 02-Dec-2013 Osteoarthritis of hip (disorder)
  • Patient will report a reduction in hip pain severity to ≤ 3 out of 10 on the pain scale within 3 months.
  • Patient will be able to walk independently for at least 30 minutes without significant discomfort within 3 months.
  • Patient will participate in low-impact physical activity (e.g., walking, swimming) at least 5 days per week for 30 minutes per session.
Lifestyle education regarding hypertension 01-Jul-1994 Essential hypertension (disorder)
  • Achieve and maintain blood pressure within recommended target range through lifestyle modifications.

Vital Signs

Vital Signs 2025-04-25 2025-02-21
Body Height 154.2 cm 154.2 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 1 {score}
Body Weight 67.3 kg 67.3 kg
Body mass index (BMI) [Ratio] 28.3 kg/m2 28.3 kg/m2
Heart rate 94 /min 89 /min
Respiratory rate 13 /min 15 /min
Blood pressure panel with all children optional 65 mm[Hg] 64 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 25-APR-2025 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 73.8 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 18.0 7 - 20 mg/dL
Creatinine [Mass/volume] in Serum or Plasma 1.9 H 0.5 - 1.1 mg/dL
Calcium [Mass/volume] in Serum or Plasma 8.7 8.6 - 10.2 mg/dL
Sodium [Moles/volume] in Serum or Plasma 142.2 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 4.0 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Serum or Plasma 104.6 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma 26.6 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 0.9 H 0 - 0 mg/dL
Glucose [Presence] in Urine by Test strip Urine glucose test = ++
Bilirubin.total [Mass/volume] in Urine by Test strip 1.5 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 18.5 0 - 20 mg/dL
Ketones [Presence] in Urine by Test strip Urine ketone test = ++
Specific gravity of Urine by Test strip 1.0 L 1.005 - 1.030 {nominal}
pH of Urine by Test strip 6.2 5.0 - 8.0 pH
Protein [Mass/volume] in Urine by Test strip 283.6 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 3.4 L 4.0 - 5.6 %
Glucose [Mass/volume] in Blood 73.8 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 18.0 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 3.1 H 0.5 - 1.1 mg/dL
Calcium [Mass/volume] in Blood 8.7 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 142.2 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.0 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 104.6 98 - 110 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 26.6 22 - 29 mmol/L

Device Use

Device Date (since)
Blood glucose meter (physical object) 10-Nov-2017
Manual wheelchair (physical object) 02-Dec-2013
Wheelchair accessory (physical object) 02-Dec-2013