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

Patient
Name: Balogh, Krisztián
DOB: 09-APR-1939 (Age: 86)
Gender: male
ID: 8637-112774-6 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 30-JUL-2024

Problem list

Condition Onset Date Status
Alzheimer's disease 19-Jul-2022 active
Ischemic heart disease 05-May-2009 active
Aortic valve stenosis 13-Dec-2000 active
Anemia 08-Feb-1994 active
Prediabetes 13-Jan-1981 active

Medication list

No known medications

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 30-Jul-2024
SARS-CoV-2 mRNA vaccine 11-May-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 26-Jun-2018

Procedure History list

Procedure Date Reason
Patient discharge 14-Jan-2022 -
Hospice care 13-Jan-2022 -
Notifications 04-Jan-2022 -
Certification procedure 04-Jan-2022 -
Initial patient assessment 04-Jan-2022 -
Development of individualized plan of care 04-Jan-2022 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
? active ?

Care Plan

Active Planned Care / Goals Start Date Reason
Dementia management 19-Jul-2022 Alzheimer's disease (disorder)
  • Support maintenance of current cognitive abilities and slow progression of cognitive decline.
  • Enable patient to perform basic activities of daily living (ADLs) with minimal assistance.
  • Minimize frequency and severity of behavioral disturbances such as agitation, aggression, or wandering.
  • Ensure patient or caregiver administers prescribed dementia medications as directed.
  • Ensure caregiver receives education and support to manage dementia-related care needs.
Discharge care plan 08-Nov-2007 History of aortic valve replacement (situation)
  • Patient and caregiver will demonstrate understanding of discharge instructions, including medication regimen, activity restrictions, and follow-up appointments.
  • All medications will be reviewed and reconciled to ensure accuracy and safety at discharge.
  • Discharge instructions will be communicated using strategies appropriate for cognitive impairment, with caregiver involvement.
  • Hemoglobin level will be maintained within the target range prior to discharge.
  • Fasting glucose will be maintained within the prediabetes range prior to discharge.
  • Patient will be hemodynamically stable with no new or worsening symptoms of ischemic heart disease or aortic valve dysfunction at discharge.
Care plan 04-Oct-2007 Aortic valve stenosis (disorder)
  • Minimize dyspnea, fatigue, and chest pain related to aortic valve stenosis
  • Maintain systolic blood pressure below 140 mmHg
  • Maintain hemoglobin above 11 g/dL
  • Monitor B-type natriuretic peptide (BNP) to detect worsening heart failure
Diabetes self management plan 13-Jan-1981 Prediabetes
  • Maintain hemoglobin A1c (HbA1c) below 6.5% to reduce risk of progression to diabetes.
  • Achieve and maintain a healthy body weight to support glycemic control.
  • Engage in at least 150 minutes of moderate-intensity physical activity per week as tolerated.
  • Adopt a balanced diet with reduced intake of simple sugars and saturated fats to support glycemic control.
  • Maintain blood pressure below 130/80 mmHg to reduce cardiovascular risk.
Immunization Recommendation Due Date Reason
Vaccine product containing only Influenza virus antigen (medicinal product) 01-Oct-2025 Annual seasonal influenza vaccination

Vital Signs

Vital Signs 2024-07-30 2023-07-25
Body Height 187.3 cm 187.3 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 2 {score} 3 {score}
Body Weight 97.6 kg 97.6 kg
Body mass index (BMI) [Ratio] 27.8 kg/m2 27.8 kg/m2
Diastolic Blood Pressure 66 mm[Hg] 66 mm[Hg]
Systolic Blood Pressure 98 mm[Hg] 90 mm[Hg]
Heart rate 100 /min 75 /min
Respiratory rate 15 /min 14 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 30-JUL-2024 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 6.1 H 4.3 - 6 %
Glucose [Mass/volume] in Blood 69.4 L 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 8.1 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 0.7 L 0.9 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.9 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 142.3 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.6 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 103.6 98 - 108 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 22.7 22 - 29 mmol/L
Leukocytes [#/volume] in Blood by Automated count 8.9 3.4 - 10.6 10*3/uL
Erythrocytes [#/volume] in Blood by Automated count 5.1 4.2 - 6.2 10*6/uL
Hemoglobin [Mass/volume] in Blood 13.6 L 13.8 - 17.5 g/dL
Hematocrit [Volume Fraction] of Blood by Automated count 39.0 38 - 50 %
MCV [Entitic volume] by Automated count 80.7 76 - 98 fL
MCH [Entitic mass] by Automated count 27.0 27 - 34 pg
MCHC [Mass/volume] by Automated count 34.5 31 - 37 g/dL
Erythrocyte distribution width [Entitic volume] by Automated count 39.4 36 - 56 fL
Platelets [#/volume] in Blood by Automated count 370.5 H 150 - 363 10*3/uL
Platelet distribution width [Entitic volume] in Blood by Automated count 392.6 H 13.4 - 17.4 fL
Platelet mean volume [Entitic volume] in Blood by Automated count 10.2 7.2 - 13.5 fL

Device Use

Device Date (since)
Blood glucose meter (physical object) 13-Jan-1981