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

Patient
Name: Green, Elaine
DOB: 05-AUG-1942 (Age: 83)
Gender: female
ID: 9467-500577-4 (ECI)
Author
Evans, Anthony
Patient summary Document
European Patient Summary
Report Date: 19-DEC-2024

Problem list

Condition Onset Date / Period Status
Macular edema and retinopathy due to type 2 diabetes mellitus 25-Nov-2021 active
Essential hypertension 21-May-2020 active
Nonproliferative retinopathy due to type 2 diabetes mellitus 14-Nov-2019 active
Osteoporosis 08-Nov-2018 active
Retinopathy due to type 2 diabetes mellitus 16-Oct-2014 active
Ischemic heart disease 17-Sep-2009 active
Hyperglycemia 25-May-1989 active
Hypertriglyceridemia 19-May-1988 active
Neuropathy due to type 2 diabetes mellitus 19-May-1988 active
Type 2 diabetes mellitus 12-Jun-1986 active
Metabolic syndrome X 12-Jun-1986 active
Hyperlipidemia 29-May-1980 active
Sepsis 28-Dec-1959 active
Fracture of forearm 03-Mar-2024 - 06-Jun-2024 inactive
Fracture of bone 03-Mar-2024 - 06-Jun-2024 inactive
Osteoporotic fracture 03-Mar-2024 - 06-Jun-2024 inactive
Viral sinusitis 04-Jun-2020 - 11-Jun-2020 inactive
Fracture of forearm 28-Sep-2017 - 07-Dec-2017 inactive
Fracture of bone 28-Sep-2017 - 07-Dec-2017 inactive
Viral sinusitis 24-Dec-2015 - 03-Jan-2016 inactive

Medication list

Medication Since Form Dosage Reason
Simvastatin 10 mg oral tablet 2024-12-19 - 1 tablet (10 mg) by mouth once daily Hyperlipidemia
Amlodipine (as amlodipine besylate) 2.5 mg oral tablet 2024-12-12 - 1 tablet (2.5 mg) by mouth once daily Essential hypertension (disorder)
Hydrochlorothiazide 25 mg oral tablet 2024-12-12 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2024-12-12 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Metformin hydrochloride 500 mg prolonged-release oral tablet 2024-12-12 - 1 tablet (500 mg) once daily Diabetes mellitus type 2 (disorder)
Alendronic acid (as alendronate sodium) 10 mg oral tablet 2024-12-12 - 1 tablet (10 mg) once daily Osteoporosis (disorder)

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 12-Dec-2024
SARS-CoV-2 mRNA vaccine 25-Mar-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 14-Nov-2019

Procedure History list

Procedure Date Reason
Pre-discharge assessment 23-Mar-2024 -
Discharge from hospital 23-Mar-2024 -
Nursing care/supplementary surveillance 22-Mar-2024 -
Professional / ancillary services care 20-Mar-2024 -
Occupational therapy 11-Mar-2024 -
Speech and language therapy regime 07-Mar-2024 -
History AND physical examination 03-Mar-2024 -
Bone immobilization 03-Mar-2024 Fracture of forearm (disorder)
Initial patient assessment 03-Mar-2024 -
Development of individualized plan of care 03-Mar-2024 -
Plain X-ray of humerus 03-Mar-2024 -
Depression screening 21-May-2020 -
Medication reconciliation 21-May-2020 -
Assessment of health and social care needs 21-May-2020 -
Assessment using Morse Fall Scale 21-May-2020 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 21-May-2020 -
Assessment of substance use 21-May-2020 -
Bone density scan 28-Sep-2017 Fracture of forearm (disorder)

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Lifestyle education regarding hypertension 21-May-2020 Essential hypertension (disorder)
  • Patient will understand and implement lifestyle modifications to help control blood pressure, including dietary changes, increased physical activity, and medication adherence.
Hyperlipidemia clinical management plan 19-Jun-1980 Hyperlipidemia (disorder)
  • Achieve and maintain LDL cholesterol below 70 mg/dL to reduce cardiovascular risk.
  • Maintain total cholesterol below 170 mg/dL.
  • Maintain triglycerides below 150 mg/dL.
  • Maintain HDL cholesterol above 50 mg/dL.
Diabetes self management plan 21-Jul-1960 Prediabetes (finding)
  • Maintain HbA1c at or below individualized target to reduce risk of diabetes complications.
  • Maintain blood pressure below 140/90 mmHg to reduce cardiovascular risk.
  • Maintain LDL cholesterol below 100 mg/dL to reduce cardiovascular risk.
  • Achieve or maintain a healthy body weight as part of diabetes self-management.
  • Maintain fasting blood glucose between 80 and 130 mg/dL.
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2024-12-12 2023-12-07
Body Height 162.8 cm 162.8 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 4 {score} 1 {score}
Body Weight 81.8 kg 81.8 kg
Body mass index (BMI) [Ratio] 30.9 kg/m2 30.9 kg/m2
Heart rate 78 /min 68 /min
Respiratory rate 15 /min 16 /min
Blood pressure panel with all children optional 62 mm[Hg] 59 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 19-DEC-2024 Reference Range Unit
Glucose [Mass/volume] in Blood 87.6 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 7.3 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 2.9 H 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.9 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 138.9 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.5 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 101.5 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 24.1 22 - 29 mmol/L
Protein [Mass/volume] in Serum or Plasma 7.3 6.6 - 8.3 g/dL
Albumin [Mass/volume] in Serum or Plasma 3.6 3.5 - 5.0 g/dL
Globulin [Mass/volume] in Serum by calculation 2.1 L 20 - 39 g/L
Bilirubin.total [Mass/volume] in Serum or Plasma 0.3 0.1 - 1.2 mg/dL
Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma 21.5 L 30 - 120 U/L
Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma 25.7 10 - 40 U/L
Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma 25.3 10 - 40 U/L
Cholesterol [Mass/volume] in Serum or Plasma 203.2 H 125 - 200 mg/dL
Triglyceride [Mass/volume] in Serum or Plasma 186.1 H 0 - 149 mg/dL
Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay 90.4 0 - 100 mg/dL
Cholesterol in HDL [Mass/volume] in Serum or Plasma 71.2 40 - 90 mg/dL

Device Use

Device Date (since)
Ventricular assist device (physical object) 30-Sep-2009
Blood glucose meter (physical object) 21-Jul-1960