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European Patient Summary
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Problem list
| Condition | Onset Date | Status |
|---|---|---|
| Ischemic heart disease | 02-Aug-2020 | active |
| Prediabetes | 08-Jun-1980 | active |
Medication list
| No known medications |
Immunizations list
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 25-Aug-2024 |
| SARS-CoV-2 mRNA vaccine | 21-Feb-2021 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 16-Jul-2017 |
Procedure History list
| Procedure | Date | Reason |
|---|---|---|
| Pre-discharge assessment | 29-Mar-2021 | - |
| Discharge from skilled nursing facility (procedure) | 29-Mar-2021 | - |
| Nursing care/supplementary surveillance | 28-Mar-2021 | - |
| Occupational therapy | 27-Mar-2021 | - |
| Professional / ancillary services care | 23-Mar-2021 | - |
| History AND physical examination | 21-Mar-2021 | - |
| Initial patient assessment | 21-Mar-2021 | - |
| Development of individualized plan of care | 21-Mar-2021 | - |
| Postoperative procedure education | 15-Aug-2020 | History of coronary artery bypass grafting (situation) |
| Stair-climbing test | 15-Aug-2020 | History of coronary artery bypass grafting (situation) |
| Walking exercise test | 15-Aug-2020 | History of coronary artery bypass grafting (situation) |
| Discharge to ward | 15-Aug-2020 | - |
| Discharge from hospital | 15-Aug-2020 | History of coronary artery bypass grafting (situation) |
| Documentation procedure | 14-Aug-2020 | - |
| Electrocardiographic procedure | 14-Aug-2020 | - |
| Echocardiography | 14-Aug-2020 | - |
| Blood group typing | 14-Aug-2020 | - |
| Intubation | 14-Aug-2020 | - |
| Pulmonary catheterization with Swan-Ganz catheter | 14-Aug-2020 | - |
| Transfusion of packed red blood cells | 14-Aug-2020 | - |
| Pre-surgery testing | 14-Aug-2020 | - |
| Preparation of patient for procedure | 14-Aug-2020 | - |
| Removal of endotracheal tube | 14-Aug-2020 | - |
| Median sternotomy | 14-Aug-2020 | - |
| Insertion of catheter into artery | 14-Aug-2020 | - |
| Plain X-ray of chest | 14-Aug-2020 | - |
| Scheduling | 14-Aug-2020 | Abnormal findings diagnostic imaging heart+coronary circulat (finding) |
| Administration of anesthesia for procedure | 14-Aug-2020 | - |
| Off-pump coronary artery bypass | 14-Aug-2020 | Ischemic heart disease (disorder) |
| Notification of treatment plan | 14-Aug-2020 | - |
Allergies and Intolerances
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| ? | active | ? |
Care Plan
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Routine antenatal care | 25-Aug-1991 | - |
| Diabetes self management plan | 08-Jun-1980 | Prediabetes |
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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 | 2024-08-25 | 2023-08-20 |
|---|---|---|
| Body Height | 153.8 cm | 153.8 cm |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 2 {score} | 1 {score} |
| Body Weight | 65.9 kg | 65.9 kg |
| Body mass index (BMI) [Ratio] | 27.9 kg/m2 | 27.9 kg/m2 |
| Diastolic Blood Pressure | 67 mm[Hg] | 69 mm[Hg] |
| Systolic Blood Pressure | 100 mm[Hg] | 100 mm[Hg] |
| Heart rate | 95 /min | 76 /min |
| Respiratory rate | 12 /min | 14 /min |
Relevant diagnostic tests/laboratory data
| Recent Lab Observations | 25-AUG-2024 | Reference Range | Unit |
|---|---|---|---|
| Hemoglobin A1c/Hemoglobin.total in Blood | 6.3 | 4.5 - 6.4 | % |
| Glucose [Mass/volume] in Blood | 79.5 | 70 - 140 | mg/dL |
| Urea nitrogen [Mass/volume] in Blood | 9.7 | 7 - 30 | mg/dL |
| Creatinine [Mass/volume] in Blood | 0.5 | 0.5 - 1.3 | mg/dL |
| Calcium [Mass/volume] in Blood | 8.5 L | 8.6 - 10.2 | mg/dL |
| Sodium [Moles/volume] in Blood | 136.5 | 135 - 145 | mmol/L |
| Potassium [Moles/volume] in Blood | 3.9 | 3.5 - 5.1 | mmol/L |
| Chloride [Moles/volume] in Blood | 108.8 | 98 - 114 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Blood | 27.5 | 22 - 32 | mmol/L |
Device Use
| Device | Date (since) |
|---|---|
| Blood glucose meter (physical object) | 08-Jun-1980 |