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European Patient Summary
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Problem list
| Condition | Onset Date | Status |
|---|---|---|
| Chronic kidney disease stage 3 | 11-Oct-2024 | active |
| Proteinuria due to type 2 diabetes mellitus | 11-Oct-2024 | active |
| Chronic kidney disease stage 2 | 02-Oct-2015 | active |
| Microalbuminuria due to type 2 diabetes mellitus | 02-Oct-2015 | active |
| Disorder of kidney due to diabetes mellitus | 21-Aug-2015 | active |
| Chronic kidney disease stage 1 | 21-Aug-2015 | active |
| Essential hypertension | 15-Aug-2014 | active |
| Chronic sinusitis | 14-May-1991 | active |
Medication list
| No known medications |
Immunizations list
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 17-May-2024 |
| SARS-CoV-2 mRNA vaccine | 04-Jun-2021 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 13-Sep-2019 |
| Live attenuated Human alphaherpesvirus 3 only vaccine product | 12-Jul-2019 |
Procedure History list
| Procedure | Date | Reason |
|---|---|---|
| Depression screening | 22-Sep-2023 | - |
| Assessment of health and social care needs | 22-Sep-2023 | - |
| Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) | 22-Sep-2023 | - |
| Assessment of substance use | 22-Sep-2023 | - |
| Depression screening using Patient Health Questionnaire Two-Item score (procedure) | 22-Sep-2023 | - |
| Assessment of anxiety | 01-Sep-2023 | - |
| Screening for drug abuse | 01-Sep-2023 | - |
| Pre-discharge assessment | 03-Jul-2023 | - |
| Discharge from skilled nursing facility (procedure) | 03-Jul-2023 | - |
| Nursing care/supplementary surveillance | 02-Jul-2023 | - |
| Physical therapy procedure | 01-Jul-2023 | - |
| Professional / ancillary services care | 01-Jul-2023 | - |
| Occupational therapy | 28-Jun-2023 | - |
| Care regimes assessment | 29-May-2023 | - |
| History AND physical examination | 26-May-2023 | - |
| Initial patient assessment | 26-May-2023 | - |
| Development of individualized plan of care | 26-May-2023 | - |
| Suture open wound | 28-Jul-2018 | Laceration of foot |
| Medication reconciliation | 07-Jul-2017 | - |
| Screening for domestic abuse | 07-Jul-2017 | - |
Allergies and Intolerances
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| ? | active | ? |
Care Plan
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Lifestyle education regarding hypertension | 15-Aug-2014 | Essential hypertension (disorder) |
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| Routine antenatal care | 02-Jan-2004 | - |
| Weight management program | 29-Jul-1977 | - |
Vital Signs
| Vital Signs | 2025-01-10 | 2024-12-13 |
|---|---|---|
| Body Height | 169.5 cm | 169.5 cm |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 3 {score} | 1 {score} |
| Body Weight | 84.8 kg | 84.8 kg |
| Body mass index (BMI) [Ratio] | 29.5 kg/m2 | 29.5 kg/m2 |
| Diastolic Blood Pressure | 72 mm[Hg] | 70 mm[Hg] |
| Systolic Blood Pressure | 115 mm[Hg] | 114 mm[Hg] |
| Heart rate | 99 /min | 70 /min |
| Respiratory rate | 13 /min | 14 /min |
Relevant diagnostic tests/laboratory data
| Recent Lab Observations | 10-JAN-2025 | Reference Range | Unit |
|---|---|---|---|
| Glucose [Mass/volume] in Serum or Plasma | 64.2 L | 70 - 139 | mg/dL |
| Urea nitrogen [Mass/volume] in Serum or Plasma | 9.9 | 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 | 8.9 | 8.4 - 10.3 | mg/dL |
| Sodium [Moles/volume] in Serum or Plasma | 141.0 | 135 - 145 | mmol/L |
| Potassium [Moles/volume] in Serum or Plasma | 4.4 | 3.5 - 5.1 | mmol/L |
| Chloride [Moles/volume] in Serum or Plasma | 105.3 | 98 - 108 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Serum or Plasma | 28.5 | 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 | 1.4 H | 0 - 0.8 | mg/dL |
| Glucose [Presence] in Urine by Test strip | ++ | ||
| Bilirubin.total [Mass/volume] in Urine by Test strip | 0.9 | 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 | 8.7 | 0 - 20 | 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 | 5.4 | 4.6 - 7 | pH |
| Protein [Mass/volume] in Urine by Test strip | 282.9 H | 0 - 14 | 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 Use
| Device | Date (since) |
|---|---|
| Home nebulizer (physical object) | 14-May-1991 |