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European Patient Summary
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Problem list
| Condition | Onset Date | Status |
|---|---|---|
| Disorder of kidney due to diabetes mellitus | 17-Feb-2025 | active |
| Chronic kidney disease stage 2 | 17-Feb-2025 | active |
| Microalbuminuria due to type 2 diabetes mellitus | 17-Feb-2025 | active |
| Essential hypertension | 24-Apr-2023 | active |
| Osteoporosis | 14-Mar-2016 | active |
| Anemia | 02-Mar-2007 | active |
| Recurrent rectal polyp | 26-Feb-2007 | active |
| Polyp of colon | 23-Jan-2006 | active |
Medication list
| No known medications |
Immunizations list
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 17-Feb-2025 |
| Streptococcus pneumoniae Danish serotype 1 | 18-Apr-2022 |
| SARS-CoV-2 mRNA vaccine | 24-May-2021 |
| Streptococcus pneumoniae Danish serotype 1 | 12-Apr-2021 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 20-Mar-2017 |
Procedure History list
| Procedure | Date | Reason |
|---|---|---|
| Medication reconciliation | 26-May-2025 | - |
| Depression screening | 19-May-2025 | - |
| Assessment of health and social care needs | 19-May-2025 | - |
| Assessment of anxiety | 19-May-2025 | - |
| Assessment using Morse Fall Scale | 19-May-2025 | - |
| Depression screening using Patient Health Questionnaire Two-Item score (procedure) | 19-May-2025 | - |
| Patient discharge | 27-Jan-2021 | - |
| Hospice care | 26-Jan-2021 | - |
| Notifications | 18-Jan-2021 | - |
| Certification procedure | 18-Jan-2021 | - |
| Initial patient assessment | 18-Jan-2021 | - |
| Development of individualized plan of care | 18-Jan-2021 | - |
Allergies and Intolerances
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| ? | active | ? |
Care Plan
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Lifestyle education regarding hypertension | 24-Apr-2023 | 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
| Vital Signs | 2025-06-16 | 2025-06-02 |
|---|---|---|
| Body Height | 174.8 cm | 174.8 cm |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 1 {score} | 3 {score} |
| Body Weight | 83.5 kg | 83.5 kg |
| Body mass index (BMI) [Ratio] | 27.3 kg/m2 | 27.3 kg/m2 |
| Diastolic Blood Pressure | 87 mm[Hg] | 86 mm[Hg] |
| Systolic Blood Pressure | 121 mm[Hg] | 121 mm[Hg] |
| Heart rate | 87 /min | 72 /min |
| Respiratory rate | 14 /min | 12 /min |
Relevant diagnostic tests/laboratory data
| Recent Lab Observations | 16-JUN-2025 | Reference Range | Unit |
|---|---|---|---|
| Glucose [Mass/volume] in Serum or Plasma | 99.6 | 70 - 140 | mg/dL |
| Urea nitrogen [Mass/volume] in Serum or Plasma | 18.8 | 7 - 45 | mg/dL |
| Creatinine [Mass/volume] in Serum or Plasma | 1.8 H | 0.9 - 1.3 | mg/dL |
| Calcium [Mass/volume] in Serum or Plasma | 9.5 | 8.5 - 10.5 | mg/dL |
| Sodium [Moles/volume] in Serum or Plasma | 137.9 | 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 | 101.8 | 98 - 111 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Serum or Plasma | 24.3 | 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 | 2.5 H | 0 - 0 | mg/dL |
| Glucose [Presence] in Urine by Test strip | ++ | ||
| Bilirubin.total [Mass/volume] in Urine by Test strip | 1.3 | 0 - 1.4 | mg/dL |
| Bilirubin.total [Presence] in Urine by Test strip | Finding of bilirubin in urine | ||
| Ketones [Mass/volume] in Urine by Test strip | 10.5 H | 0 - 8 | 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 | 5.9 | 4.6 - 7 | pH |
| Protein [Mass/volume] in Urine by Test strip | 326.3 H | 0 - 149 | 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 |