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| Condition | Onset Date | Status |
|---|---|---|
| Chronic kidney disease stage 3 | 11-Jul-2019 | active |
| Proteinuria due to type 2 diabetes mellitus | 11-Jul-2019 | active |
| Alzheimer's disease | 28-Sep-2017 | active |
| Chronic kidney disease stage 2 | 05-Jan-2017 | active |
| Microalbuminuria due to type 2 diabetes mellitus | 05-Jan-2017 | active |
| Disorder of kidney due to diabetes mellitus | 26-Jul-2012 | active |
| Chronic kidney disease stage 1 | 26-Jul-2012 | active |
| Osteoporosis | 24-May-2001 | active |
| Ischemic heart disease | 25-Apr-1996 | active |
| Chronic sinusitis | 11-May-1987 | active |
| Essential hypertension | 11-Sep-1958 | active |
| No known medications |
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 23-Jan-2025 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 12-Aug-2021 |
| SARS-CoV-2 mRNA vaccine | 11-Mar-2021 |
| Procedure | Date | Reason |
|---|---|---|
| Notifications | 24-Jul-2025 | - |
| Certification procedure | 24-Jul-2025 | - |
| Initial patient assessment | 24-Jul-2025 | - |
| Development of individualized plan of care | 24-Jul-2025 | - |
| Hospice care | 24-Jul-2025 | - |
| Depression screening | 17-Jul-2025 | - |
| Assessment of health and social care needs | 17-Jul-2025 | - |
| Assessment of anxiety | 17-Jul-2025 | - |
| Assessment using Morse Fall Scale | 17-Jul-2025 | - |
| Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) | 17-Jul-2025 | - |
| Assessment of substance use | 17-Jul-2025 | - |
| Depression screening using Patient Health Questionnaire Two-Item score (procedure) | 17-Jul-2025 | - |
| Medication reconciliation | 19-Jun-2025 | - |
| Screening for drug abuse | 19-Jun-2025 | - |
| Screening for domestic abuse | 19-Jun-2025 | - |
| Depression screening using PHQ-9 (Patient Health Questionnaire 9) score | 23-Jan-2025 | - |
| Patient discharge | 10-Aug-2015 | - |
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| ? | active | ? |
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Dementia management | 28-Sep-2017 | Alzheimer's disease (disorder) |
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| Lifestyle education regarding hypertension | 11-Sep-1958 | Essential hypertension (disorder) |
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| Immunization Recommendation | Due Date | Reason |
| Vaccine product containing only Influenza virus antigen (medicinal product) | 01-Oct-2025 | Annual seasonal influenza vaccination |
| Vital Signs | 2025-07-17 | 2025-06-19 |
|---|---|---|
| Body Height | 162.7 cm | 162.7 cm |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 2 {score} | 1 {score} |
| Body Weight | 73.3 kg | 73.3 kg |
| Body mass index (BMI) [Ratio] | 27.7 kg/m2 | 27.7 kg/m2 |
| Diastolic Blood Pressure | 50 mm[Hg] | 51 mm[Hg] |
| Systolic Blood Pressure | 92 mm[Hg] | 99 mm[Hg] |
| Heart rate | 91 /min | 92 /min |
| Respiratory rate | 16 /min | 13 /min |
| Recent Lab Observations | 17-JUL-2025 | Reference Range | Unit |
|---|---|---|---|
| Glucose [Mass/volume] in Serum or Plasma | 79.3 | 70 - 140 | mg/dL |
| Urea nitrogen [Mass/volume] in Serum or Plasma | 12.8 | 7 - 20 | mg/dL |
| Creatinine [Mass/volume] in Serum or Plasma | 1.9 H | 0.6 - 1.1 | mg/dL |
| Calcium [Mass/volume] in Serum or Plasma | 9.8 | 8.5 - 10.4 | mg/dL |
| Sodium [Moles/volume] in Serum or Plasma | 136.0 | 135 - 145 | mmol/L |
| Potassium [Moles/volume] in Serum or Plasma | 5.0 | 3.5 - 5.1 | mmol/L |
| Chloride [Moles/volume] in Serum or Plasma | 109.3 H | 98 - 108 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Serum or Plasma | 21.5 L | 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 | 1.8 H | 0 - 0.8 | mg/dL |
| Glucose [Presence] in Urine by Test strip | ++ | ||
| Bilirubin.total [Mass/volume] in Urine by Test strip | 1.3 H | 0 - 1 | mg/dL |
| Bilirubin.total [Presence] in Urine by Test strip | Finding of bilirubin in urine | ||
| Ketones [Mass/volume] in Urine by Test strip | 16.9 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 | 1.01 - 1.03 | {nominal} |
| pH of Urine by Test strip | 5.1 | 4.5 - 7.5 | pH |
| Protein [Mass/volume] in Urine by Test strip | 278.1 H | 30 - 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 |
| Device | Date (since) |
|---|---|
| Hospital bed | 24-Jul-2025 |
| Home nebulizer (physical object) | 11-May-1987 |