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

Patient
Name: Rémy, Yves
DOB: 16-MAY-1948 (Age: 77)
Gender: male
ID: 4543-821530-8 (ECI)
Author
Lombard, Vincent
Patient summary Document
European Patient Summary
Report Date: 13-JUL-2025

Problem list

Condition Onset Date / Period Status
Chronic congestive heart failure 19-Jan-2025 active
Chronic kidney disease stage 2 09-Sep-2018 active
Microalbuminuria due to type 2 diabetes mellitus 09-Sep-2018 active
Disorder of kidney due to diabetes mellitus 17-Sep-2017 active
Chronic kidney disease stage 1 17-Sep-2017 active
Ischemic heart disease 04-Jul-2010 active
Osteoporosis 05-Jun-2005 active
Metabolic syndrome X 07-Nov-1999 active
Anemia 14-Apr-1996 active
Essential hypertension 16-Feb-1986 active
Gout 30-Sep-1983 active
Viral sinusitis 22-Dec-2024 - 07-Jan-2025 inactive
Laceration of thigh 01-Aug-2023 - 28-Aug-2023 inactive
Laceration - injury 01-Aug-2023 - 28-Aug-2023 inactive
Viral sinusitis 14-May-2023 - 24-May-2023 inactive
Acute viral pharyngitis 28-Apr-2019 - 11-May-2019 inactive
Viral sinusitis 25-Sep-2016 - 17-Oct-2016 inactive
Acute bronchitis 29-Nov-2015 - 09-Dec-2015 inactive
Viral sinusitis 29-Nov-2015 - 14-Dec-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 2025-07-13 - Inject 10 units (0.1 mL) subcutaneously before breakfast and 10 units (0.1 mL) before dinner Prediabetes
Carvedilol 25 mg oral tablet 2025-07-13 - 1 tablet (25 mg) twice daily Chronic congestive heart failure (disorder)
Hydrochlorothiazide 25 mg oral tablet 2025-07-13 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Furosemide 40 mg oral tablet 2025-07-13 - 1 tablet (40 mg) once daily Chronic congestive heart failure (disorder)
Lisinopril 10 mg oral tablet 2025-07-13 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Budesonide 250 microgram/mL suspension for nebulizer 2025-07-13 - 250 micrograms via nebulizer twice daily Childhood asthma
Albuterol (as albuterol sulfate) 830 microgram/mL solution for inhalation 2025-07-13 - 2.5 mg (3 mL of 830 microgram/mL solution) via nebulizer every 6 hours as needed Childhood asthma
Alendronic acid (as alendronate sodium) 10 mg oral tablet 2025-07-13 - 1 tablet (10 mg) once daily Osteoporosis (disorder)
Losartan potassium 50 mg oral tablet 2025-07-13 - 1 tablet (50 mg) by mouth once daily Chronic congestive heart failure (disorder)
Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet 2010-07-11 - 1 tablet (75 mg) by mouth once daily -
Simvastatin 20 mg oral tablet 2010-07-11 - 1 tablet (20 mg) by mouth once daily -
Nitroglycerin 400 microgram/actuation sublingual spray 2010-07-11 - 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 2010-07-11 - 1 tablet (100 mg) once daily -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 09-Mar-2025
SARS-CoV-2 mRNA vaccine 28-Feb-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 04-Oct-2015

Procedure History list

Procedure Date Reason
Depression screening 06-Jul-2025 -
Assessment of health and social care needs 06-Jul-2025 -
Screening for domestic abuse 06-Jul-2025 -
Screening for substance abuse 09-Mar-2025 -
Medication reconciliation 09-Mar-2025 -
Assessment of anxiety 09-Mar-2025 -
Assessment of substance use 09-Mar-2025 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 05-Jan-2025 -
Assessment using Morse Fall Scale 10-Nov-2024 -
Depression screening using PHQ-9 (Patient Health Questionnaire 9) score 27-Oct-2024 -
Suture open wound 01-Aug-2023 Laceration of thigh (disorder)

Allergies and Intolerances

No known allergies or intolerances

Care Plan

Active Planned Care / Goals Start Date Reason
Heart failure self management plan 02-Feb-2025 Chronic congestive heart failure (disorder)
  • Patient will monitor and record weight daily to detect early signs of fluid retention.
  • Patient will adhere to a sodium-restricted diet as recommended.
  • Patient will limit daily fluid intake as recommended.
  • Patient will maintain blood pressure within the individualized target range.
  • Patient will recognize and promptly report symptoms of heart failure exacerbation such as increased shortness of breath, swelling, or rapid weight gain.
Diabetes self management plan 14-Apr-1996 Prediabetes (finding)
  • Achieve and maintain a healthy body weight to reduce risk of progression from prediabetes to diabetes
  • Maintain HbA1c below diabetes diagnostic threshold
  • Maintain blood pressure within recommended range for cardiovascular and renal protection
  • Engage in at least 150 minutes of moderate-intensity physical activity per week
  • Follow a balanced diet with reduced simple sugars and saturated fats to support glycemic control and cardiovascular health
  • Reduce urinary albumin excretion to slow progression of diabetic kidney disease
Lifestyle education regarding hypertension 16-Feb-1986 Essential hypertension (disorder)
  • Achieve and maintain systolic blood pressure below 130 mmHg through lifestyle modifications.
  • Achieve and maintain diastolic blood pressure below 80 mmHg through lifestyle modifications.
Musculoskeletal care 30-Sep-1983 -
Asthma self management 08-Jun-1948 Childhood asthma (disorder)
  • Patient will demonstrate effective self-management of asthma symptoms, including correct inhaler technique and adherence to prescribed therapy.
Immunization Recommendation Due Date Reason
Influenza virus antigen only vaccine product 01-Oct-2026 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2025-07-06 2025-06-08
Body Height 166.8 cm 166.8 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 0 {score}
Body Weight 104.1 kg 104.1 kg
Body mass index (BMI) [Ratio] 37.4 kg/m2 37.4 kg/m2
Heart rate 96 /min 71 /min
Respiratory rate 15 /min 13 /min
Blood pressure panel with all children optional 50 mm[Hg] 48 mm[Hg]

Relevant diagnostic tests/laboratory data

Recent Lab Observations 13-JUL-2025 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 75.1 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 19.6 7 - 20 mg/dL
Creatinine [Mass/volume] in Serum or Plasma 2.0 H 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Serum or Plasma 9.3 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Serum or Plasma 136.9 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 4.5 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Serum or Plasma 101.7 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma 24.7 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 0.7 0 - 0.8 mg/dL
Glucose [Presence] in Urine by Test strip Urine glucose test = ++
Bilirubin.total [Mass/volume] in Urine by Test strip 0.3 0.0 - 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 3.4 0 - 4 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 5.2 4.5 - 8.0 pH
Protein [Mass/volume] in Urine by Test strip 306.8 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 2.8 L 4.0 - 5.6 %

Device Use

Device Date (since)
Blood glucose meter (physical object) 14-Apr-1996