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

Patient
Name: Jenkins, , Molly,
DOB: 14-AUG-1967 (Age: 58)
Gender: female
ID: 7634-012682-0 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 24-OCT-2024

Problem list

Condition Onset Date Status
Chronic kidney disease stage 2 17-Apr-2008 active
Microalbuminuria due to type 2 diabetes mellitus 17-Apr-2008 active
Disorder of kidney due to diabetes mellitus 23-Mar-2006 active
Chronic kidney disease stage 1 23-Mar-2006 active
Prediabetes 04-Apr-2002 active
Essential hypertension 19-Jan-1989 active
Excessive salivation 26-Dec-1963 active
Osteoporosis 26-Dec-1963 active
Cerebral palsy 26-Dec-1963 active
Gastroesophageal reflux disease 26-Dec-1963 active

Medication list

Medication Since Form Dosage Reason
insulin isophane human 70 UNT/ML / insulin regular human 30 UNT/ML Injectable Suspension [Humulin] 2024-10-24 - 10 units subcutaneously twice daily Prediabetes
Amlodipine (as amlodipine besylate) 2.5 mg oral tablet 2024-10-24 - 1 tablet (2.5 mg) by mouth once daily Essential hypertension (disorder)
Hydrochlorothiazide 25 mg oral tablet 2024-10-24 - 1 tablet (25 mg) by mouth once daily Essential hypertension (disorder)
Lisinopril 10 mg oral tablet 2024-10-24 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
Alendronic acid (as alendronate sodium) 10 mg oral tablet 2024-10-24 - 1 tablet (10 mg) once daily -
Vitamin B12 5 MG/ML Injectable Solution 1983-03-24 - 1 mL (5 mg) intramuscularly once monthly -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 16-May-2024
SARS-CoV-2 mRNA vaccine 13-May-2021

Procedure History list

Procedure Date Reason
Depression screening 16-May-2024 -
Medication reconciliation 16-May-2024 -
Assessment of health and social care needs 16-May-2024 -
Assessment of anxiety 16-May-2024 -
Screening for drug abuse 16-May-2024 -
Assessment of substance use 16-May-2024 -
Depression screening using Patient Health Questionnaire Two-Item score (procedure) 16-May-2024 -
Assessment using Morse Fall Scale 14-Sep-2023 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
? active ?

Care Plan

Active Planned Care / Goals Start Date Reason
Diabetes self management plan 04-Apr-2002 Prediabetes
  • Patient will demonstrate understanding of diabetes self-management strategies including diet, exercise, and blood glucose monitoring.
  • Maintain hemoglobin A1c below 6.5% to reduce risk of diabetes progression.
  • Maintain fasting plasma glucose below 100 mg/dL to prevent progression to diabetes.
  • Achieve at least 5% reduction in body weight from baseline to improve glycemic control.
  • Engage in at least 150 minutes of moderate-intensity physical activity per week as part of diabetes self-management.
Lifestyle education regarding hypertension 19-Jan-1989 Essential hypertension (disorder)
  • Achieve and maintain blood pressure within target range through lifestyle modifications.

Vital Signs

Vital Signs 2024-10-24 2024-08-08
Body Height 154.6 cm 154.6 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 2 {score}
Body Weight 66.4 kg 66.4 kg
Body mass index (BMI) [Ratio] 27.8 kg/m2 27.8 kg/m2
Diastolic Blood Pressure 57 mm[Hg] 47 mm[Hg]
Systolic Blood Pressure 93 mm[Hg] 93 mm[Hg]
Heart rate 89 /min 79 /min
Respiratory rate 13 /min 13 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 24-OCT-2024 Reference Range Unit
Glucose [Mass/volume] in Serum or Plasma 68.9 L 70 - 139 mg/dL
Urea nitrogen [Mass/volume] in Serum or Plasma 10.9 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 9.0 8.5 - 10.4 mg/dL
Sodium [Moles/volume] in Serum or Plasma 141.4 135 - 145 mmol/L
Potassium [Moles/volume] in Serum or Plasma 5.1 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Serum or Plasma 103.4 98 - 110 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 1.7 H 0 - 0 mg/dL
Glucose [Presence] in Urine by Test strip ++
Bilirubin.total [Mass/volume] in Urine by Test strip 0.9 0 - 1.6 mg/dL
Bilirubin.total [Presence] in Urine by Test strip Finding of bilirubin in urine
Ketones [Mass/volume] in Urine by Test strip 7.4 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 1.005 - 1.03 {nominal}
pH of Urine by Test strip 5.8 4.5 - 7.5 pH
Protein [Mass/volume] in Urine by Test strip 259.1 H 0 - 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
Hemoglobin A1c/Hemoglobin.total in Blood 3.2 L 4 - 6 %
Glucose [Mass/volume] in Blood 68.9 L 70 - 100 mg/dL
Urea nitrogen [Mass/volume] in Blood 10.9 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 1.9 H 0.6 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.0 8.6 - 10.4 mg/dL
Sodium [Moles/volume] in Blood 141.4 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 5.1 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 103.4 98 - 110 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 21.5 L 22 - 29 mmol/L

Device Use

Device Date (since)
Blood glucose meter (physical object) 04-Apr-2002