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

Patient
Name: Köhler, , Leonhard,
DOB: 19-DEC-1949 (Age: 75)
Gender: male
ID: 5321-442678-4 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 19-NOV-2024

Problem list

Condition Onset Date Status
Hyperlipidemia 12-Aug-2016 active
Ischemic heart disease 09-Jul-2010 active
Essential hypertension 16-Jun-2006 active
Osteoarthritis of knee 09-Sep-2003 active
Anemia 12-Jul-1974 active
Prediabetes 09-Jul-1971 active

Medication list

Medication Since Form Dosage Reason
Simvastatin 10 mg oral tablet 2024-10-04 - 1 tablet (10 mg) by mouth once daily Hyperlipidemia
Amlodipine (as amlodipine besylate) 2.5 mg oral tablet 2024-09-27 - 1 tablet (2.5 mg) by mouth once daily Essential hypertension (disorder)
Hydrochlorothiazide 25 mg oral tablet 2024-09-27 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2024-09-27 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet 2010-07-16 - 1 tablet (75 mg) once daily -
Simvastatin 20 mg oral tablet 2010-07-16 - 1 tablet (20 mg) by mouth once daily -
Nitroglycerin 400 microgram/actuation sublingual spray 2010-07-16 - 400 micrograms per spray, 1 spray under the tongue as needed for chest pain, may repeat every 5 minutes as needed, up to 3 sprays in 15 minutes -
Metoprolol tartrate (as metoprolol succinate) 100 mg prolonged-release oral tablet 2010-07-16 - 1 tablet (100 mg) once daily -
Naproxen sodium 220 mg oral capsule 2003-09-09 - 1 tablet (220 mg) by mouth every 12 hours as needed Osteoarthritis of knee

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 01-Dec-2023
SARS-CoV-2 mRNA vaccine 30-Apr-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 04-Sep-2020
Streptococcus pneumoniae Danish serotype 1 07-Aug-2015

Procedure History list

Procedure Date Reason
Patient evaluation and management 19-Nov-2024 -
Urine specimen collection 19-Nov-2024 -
Patient discharge 19-Nov-2024 -
Taking patient vital signs 19-Nov-2024 -
Antibiotic therapy 19-Nov-2024 -
Triage: emergency center 19-Nov-2024 -
Urinalysis with reflex to microscopy and culture 19-Nov-2024 -
Depression screening 01-Dec-2023 -
Assessment of health and social care needs 01-Dec-2023 -
Assessment using Morse Fall Scale 01-Dec-2023 -
Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) 01-Dec-2023 -
Assessment of substance use 01-Dec-2023 -
Depression screening using Patient Health Questionnaire Two-Item score (procedure) 01-Dec-2023 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
? active ?

Care Plan

Active Planned Care / Goals Start Date Reason
Hyperlipidemia clinical management plan 02-Sep-2016 Hyperlipidemia
  • Achieve LDL cholesterol below 70 mg/dL to reduce cardiovascular risk.
  • Maintain total cholesterol below 200 mg/dL.
  • Maintain HDL cholesterol above 40 mg/dL.
  • Maintain triglycerides below 150 mg/dL.
Lifestyle education regarding hypertension 16-Jun-2006 Essential hypertension (disorder)
  • Maintain blood pressure below 130/80 mm[Hg] through lifestyle modifications.
  • Limit daily sodium intake to less than 2.3 g to support blood pressure control.
  • Engage in at least 150 minutes of moderate-intensity aerobic physical activity per week.
  • Achieve a 5% reduction in body weight from baseline.
  • Limit alcohol consumption to no more than 2 standard drinks per day.
Musculoskeletal care 09-Sep-2003 Osteoarthritis of knee
  • Reduce knee pain severity to a tolerable level to improve mobility and quality of life.
  • Increase ability to walk and perform daily activities without significant limitation from knee osteoarthritis.
  • Patient will perform prescribed knee strengthening and flexibility exercises at least 5 days per week.
Diabetes self management plan 09-Jul-1971 Prediabetes
  • Achieve and maintain Hemoglobin A1c below prediabetes threshold through lifestyle modification.
  • Achieve and maintain a healthy body weight to reduce risk of progression to diabetes.
  • Maintain blood pressure below 130/80 mmHg as part of diabetes risk reduction.
  • Maintain LDL cholesterol below 100 mg/dL 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 2024-11-19 2024-09-27
Diastolic Blood Pressure 78.6 mm[Hg] 53 mm[Hg]
Systolic Blood Pressure 126.9 mm[Hg] 103 mm[Hg]
Heart rate 95 /min 72 /min
Respiratory rate 14 /min 14 /min
Oxygen saturation in Arterial blood 99.5 % -
Body temperature 36.8 Cel -
Body Height - 185.6 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported - 3 {score}
Body Weight - 94.3 kg
Body mass index (BMI) [Ratio] - 27.4 kg/m2

Relevant diagnostic tests/laboratory data

Recent Lab Observations 19-NOV-2024 Reference Range Unit
Glucose [Mass/volume] in Urine by Test strip 2.9 H 0 - 0.8 mg/dL
Ketones [Presence] in Urine by Test strip Urine ketone test negative
Specific gravity of Urine by Test strip 1.0 L 1.005 - 1.03 {nominal}
pH of Urine by Test strip 6.6 4.5 - 7.5 pH
Protein [Mass/volume] in Urine by Test strip 10.5 L 14 - 20 mg/dL
Nitrite [Presence] in Urine by Test strip Urine nitrite positive
Hemoglobin [Presence] in Urine by Test strip Urine blood test = +
Leukocyte esterase [Presence] in Urine by Test strip Urine leukocyte test
Leukocytes [#/area] in Urine sediment by Microscopy high power field 44.4 H 0 - 5 /[HPF]
Erythrocytes [#/area] in Urine sediment by Microscopy high power field 2.0 0 - 5 /[HPF]
Epithelial cells [#/area] in Urine sediment by Microscopy high power field 0.5 0 - 5 /[HPF]
Casts [Presence] in Urine sediment by Light microscopy Urine microscopy: no casts
Mucus [Presence] in Urine sediment by Light microscopy Mucus in urine
Bacteria [#/area] in Urine sediment by Microscopy high power field Finding of presence of bacteria
Bacteria identified in Urine by Culture

Device Use

Device Date (since)
Manual wheelchair (physical object) 09-Sep-2003
Wheelchair accessory (physical object) 09-Sep-2003
Blood glucose meter (physical object) 09-Jul-1971