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            For up-to-date information on a medicine, please consult www.ema.europa.eu/medicines or the package leaflet of your medicine. 
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| Condition | Onset Date | Status | 
|---|---|---|
| Hyperlipidemia | 25-Jun-2024 | active | 
| Chronic kidney disease stage 3 | 23-Apr-2019 | active | 
| Proteinuria due to type 2 diabetes mellitus | 23-Apr-2019 | active | 
| Chronic kidney disease stage 2 | 27-Aug-2013 | active | 
| Microalbuminuria due to type 2 diabetes mellitus | 27-Aug-2013 | active | 
| Disorder of kidney due to diabetes mellitus | 18-Jul-2006 | active | 
| Chronic kidney disease stage 1 | 18-Jul-2006 | active | 
| Metabolic syndrome X | 02-Jun-1998 | active | 
| Anemia | 27-May-1997 | active | 
| Prediabetes | 10-May-1994 | active | 
| Essential hypertension | 16-Apr-1991 | active | 
| Medication | Since | Form | Dosage | Reason | 
|---|---|---|---|---|
| Simvastatin 10 mg oral tablet | 2025-07-15 | - | 1 tablet (10 mg) by mouth once daily | Hyperlipidemia | 
| insulin isophane human 70 UNT/ML / insulin regular human 30 UNT/ML Injectable Suspension [Humulin] | 2025-06-16 | - | 10 units subcutaneously twice daily before breakfast and dinner | Prediabetes | 
| Amlodipine (as amlodipine besylate) 2.5 mg oral tablet | 2025-06-16 | - | 1 tablet (2.5 mg) by mouth once daily | Essential hypertension (disorder) | 
| Vitamin B12 5 MG/ML Injectable Solution | 1997-06-02 | - | 5 mg (1 mL) intramuscularly once weekly | - | 
| Vaccine | Date | 
|---|---|
| Influenza virus antigen only vaccine product | 28-Apr-2025 | 
| Streptococcus pneumoniae Danish serotype 1 | 21-Oct-2024 | 
| Streptococcus pneumoniae Danish serotype 1 | 11-Dec-2023 | 
| SARS-CoV-2 mRNA vaccine | 20-Dec-2021 | 
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 30-Sep-2019 | 
| Procedure | Date | Reason | 
|---|---|---|
| Depression screening | 20-May-2025 | - | 
| Screening for domestic abuse | 20-May-2025 | - | 
| Depression screening using Patient Health Questionnaire Two-Item score (procedure) | 20-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 | - | 
| Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) | 18-Mar-2025 | - | 
| Assessment of substance use | 18-Mar-2025 | - | 
| Medication reconciliation | 17-Mar-2025 | - | 
| Screening for drug abuse | 21-May-2024 | - | 
| Pre-discharge assessment | 01-Dec-2023 | - | 
| Discharge from skilled nursing facility (procedure) | 01-Dec-2023 | - | 
| Nursing care/supplementary surveillance | 30-Nov-2023 | - | 
| Occupational therapy | 29-Nov-2023 | - | 
| Professional / ancillary services care | 22-Nov-2023 | - | 
| Physical therapy procedure | 18-Nov-2023 | - | 
| Speech and language therapy regime | 31-Oct-2023 | - | 
| Care regimes assessment | 23-Oct-2023 | - | 
| History AND physical examination | 02-Oct-2023 | - | 
| Initial patient assessment | 02-Oct-2023 | - | 
| Development of individualized plan of care | 02-Oct-2023 | - | 
| Depression screening using PHQ-9 (Patient Health Questionnaire 9) score | 19-Jul-2022 | - | 
| Radiography of wrist | 27-Dec-2015 | - | 
| Bone immobilization | 27-Dec-2015 | Fracture subluxation of wrist | 
| Bone density scan | 27-Dec-2015 | Fracture subluxation of wrist | 
| Allergy/Intolerance | Onset Date | Status | Type | Reaction | 
|---|---|---|---|---|
| ? | active | ? | 
| Active Planned Care / Goals | Start Date | Reason | 
|---|---|---|
| Hyperlipidemia clinical management plan | 16-Jul-2024 | Hyperlipidemia | 
                           
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| Diabetes self management plan | 10-May-1994 | Prediabetes | 
                           
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| Lifestyle education regarding hypertension | 16-Apr-1991 | 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 | 2025-06-16 | 2025-05-19 | 
|---|---|---|
| Body Height | 169.5 cm | 169.5 cm | 
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 1 {score} | 2 {score} | 
| Body Weight | 80.6 kg | 80.6 kg | 
| Body mass index (BMI) [Ratio] | 28.1 kg/m2 | 28.1 kg/m2 | 
| Diastolic Blood Pressure | 91 mm[Hg] | 89 mm[Hg] | 
| Systolic Blood Pressure | 111 mm[Hg] | 110 mm[Hg] | 
| Heart rate | 79 /min | 65 /min | 
| Respiratory rate | 14 /min | 14 /min | 
| Recent Lab Observations | 16-JUL-2025 | Reference Range | Unit | 
|---|---|---|---|
| Glucose [Mass/volume] in Blood | 75.1 | 70 - 100 | mg/dL | 
| Urea nitrogen [Mass/volume] in Blood | 18.0 | 7 - 43 | mg/dL | 
| Creatinine [Mass/volume] in Blood | 2.9 H | 0.6 - 1.1 | mg/dL | 
| Calcium [Mass/volume] in Blood | 9.8 | 8.5 - 10.5 | mg/dL | 
| Sodium [Moles/volume] in Blood | 137.5 | 135 - 145 | mmol/L | 
| Potassium [Moles/volume] in Blood | 4.6 | 3.5 - 5.1 | mmol/L | 
| Chloride [Moles/volume] in Blood | 105.3 | 98 - 108 | mmol/L | 
| Carbon dioxide, total [Moles/volume] in Blood | 25.3 | 22 - 29 | mmol/L | 
| Protein [Mass/volume] in Serum or Plasma | 6.7 | 6 - 8.3 | g/dL | 
| Albumin [Mass/volume] in Serum or Plasma | 5.2 | 3.5 - 5.5 | g/dL | 
| Globulin [Mass/volume] in Serum by calculation | 3.2 | 2 - 3.5 | g/L | 
| Bilirubin.total [Mass/volume] in Serum or Plasma | 0.1 L | 0.3 - 1.2 | mg/dL | 
| Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma | 80.2 | 44 - 130 | U/L | 
| Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma | 53.4 | 0 - 55 | U/L | 
| Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma | 10.6 | 10 - 40 | U/L | 
| Cholesterol [Mass/volume] in Serum or Plasma | 199.1 | 125 - 239 | mg/dL | 
| Triglyceride [Mass/volume] in Serum or Plasma | 113.4 | mg/dL | |
| Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay | 142.4 H | 0 - 130 | mg/dL | 
| Cholesterol in HDL [Mass/volume] in Serum or Plasma | 74.2 | 50 - 100 | mg/dL | 
| Device | Date (since) | 
|---|---|
| Blood glucose meter (physical object) | 09-May-1994 |