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

Patient
Name: Gallet, , Hortense,
DOB: 14-FEB-1967 (Age: 58)
Gender: female
ID: 7727-126450-7 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 15-APR-2025

Problem list

Condition Onset Date Status
Chronic kidney disease stage 2 06-Feb-2024 active
Microalbuminuria due to type 2 diabetes mellitus 06-Feb-2024 active
Disorder of kidney due to diabetes mellitus 29-Mar-2022 active
Chronic kidney disease stage 1 29-Mar-2022 active
Essential hypertension 16-Dec-2003 active

Medication list

Medication Since Form Dosage Reason
Amlodipine (as amlodipine besylate) 2.5 mg oral tablet 2025-04-15 - 1 tablet (2.5 mg) by mouth once daily Essential hypertension (disorder)
Hydrochlorothiazide 25 mg oral tablet 2025-04-15 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2025-04-15 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)

Immunizations list

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

Procedure History list

Procedure Date Reason
Suture open wound 23-Apr-2024 Laceration of thigh
Depression screening 13-Dec-2022 -
Medication reconciliation 13-Dec-2022 -
Assessment of health and social care needs 13-Dec-2022 -
Assessment of anxiety 13-Dec-2022 -
Screening for domestic abuse 13-Dec-2022 -
Depression screening using Patient Health Questionnaire Two-Item score (procedure) 13-Dec-2022 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 29-Nov-2022 -
Assessment of substance use 29-Nov-2022 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
Inadequate digital access affecting health care 2025-10-22 active environment

Care Plan

Active Planned Care / Goals Start Date Reason
Lifestyle education regarding hypertension 16-Dec-2003 Essential hypertension (disorder)
  • Maintain blood pressure below 130/80 mmHg to reduce risk of kidney disease progression and cardiovascular complications.
  • Implement dietary changes, increase physical activity, and reduce sodium intake to support blood pressure control.
Routine antenatal care 09-Jan-1996 -

Vital Signs

Vital Signs 2025-04-15 2025-01-28
Body Height 172.4 cm 172.4 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 1 {score}
Body Weight 102.9 kg 102.9 kg
Body mass index (BMI) [Ratio] 34.6 kg/m2 34.6 kg/m2
Diastolic Blood Pressure 79 mm[Hg] 79 mm[Hg]
Systolic Blood Pressure 103 mm[Hg] 94 mm[Hg]
Heart rate 72 /min 87 /min
Respiratory rate 14 /min 14 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 15-APR-2025 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 74.5 70 - 139 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 7.7 7 - 20 mg/dL
Creatinine [Mass/volume] in Serum or Plasma 2.0 H 0.6 - 1.1 mg/dL
Calcium [Mass/volume] in Serum or Plasma 9.5 8.5 - 10.4 mg/dL
Sodium [Moles/volume] in Serum or Plasma 138.4 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 4.3 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Serum or Plasma 101.8 98 - 110 mmol/L
Carbon dioxide, total [Moles/volume] in Serum or Plasma 22.7 22 - 32 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 2.4 H 0 - 0 mg/dL
Glucose [Presence] in Urine by Test strip ++
Bilirubin.total [Mass/volume] in Urine by Test strip 1.4 0 - 1.6 mg/dL
Bilirubin.total [Presence] in Urine by Test strip Finding of bilirubin in urine
Ketones [Mass/volume] in Urine by Test strip 14.2 H 0 - 0.5 mg/dL
Ketones [Presence] in Urine by Test strip Urine ketone test = +
Specific gravity of Urine by Test strip 1.0 L 1.005 - 1.03 {nominal}
pH of Urine by Test strip 6.7 4.5 - 7.5 pH
Protein [Mass/volume] in Urine by Test strip 169.0 H 0 - 15 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