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

Patient
Name: Gerlach, , Marlene,
DOB: 28-AUG-1939 (Age: 86)
Gender: female
ID: 4536-398571-9 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 04-MAY-2025

Problem list

Condition Onset Date Status
Hyperlipidemia 24-Jan-2010 active
Ischemic heart disease 10-Aug-1980 active
Proteinuria due to type 2 diabetes mellitus 08-Jun-1969 active
Microalbuminuria due to type 2 diabetes mellitus 02-Mar-1969 active
Disorder of kidney due to diabetes mellitus 28-Apr-1968 active
Anemia 22-May-1966 active
Prediabetes 16-May-1965 active
Essential hypertension 23-Apr-1961 active

Medication list

Medication Since Form Dosage Reason
insulin isophane human 70 UNT/ML / insulin regular human 30 UNT/ML Injectable Suspension [Humulin] 2025-05-04 - 10 units subcutaneously twice daily before breakfast and dinner Prediabetes
Lisinopril 10 mg oral tablet 2025-05-04 - 1 tablet (10 mg) by mouth once daily Essential hypertension (disorder)
24 HR tacrolimus 1 MG Extended Release Oral Tablet 2025-05-04 - 1 tablet (1 mg) by mouth once daily History of renal transplant (situation)
Simvastatin 10 mg oral tablet 2025-03-28 - 1 tablet (10 mg) by mouth once daily Hyperlipidemia
Nitroglycerin 400 microgram/actuation sublingual spray 1980-08-17 - 1 spray (400 micrograms) 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 1980-08-17 - 1 tablet (100 mg) once daily -

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 04-May-2025
SARS-CoV-2 mRNA vaccine 05-Sep-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 05-Mar-2017

Procedure History list

Procedure Date Reason
Admission to orthopedic department 09-Oct-2021 Fracture of clavicle
Bone density scan 09-Oct-2021 Fracture of clavicle
Plain X-ray of clavicle 08-Oct-2021 -
Patient discharge 02-Apr-2021 -
Hospice care 01-Apr-2021 -
Notifications 21-Feb-2021 -
Certification procedure 21-Feb-2021 -
Initial patient assessment 21-Feb-2021 -
Development of individualized plan of care 21-Feb-2021 -
Depression screening 27-May-2018 -
Assessment of health and social care needs 27-May-2018 -
Screening for drug abuse 27-May-2018 -
Assessment using Morse Fall Scale 27-May-2018 -
Screening for domestic abuse 27-May-2018 -
Assessment of substance use 27-May-2018 -
Depression screening using Patient Health Questionnaire Two-Item score (procedure) 27-May-2018 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
? active ?

Care Plan

Active Planned Care / Goals Start Date Reason
Hyperlipidemia clinical management plan 14-Feb-2010 Hyperlipidemia
  • Achieve and maintain LDL cholesterol below 70 mg/dL to reduce cardiovascular risk.
  • Keep total cholesterol below 200 mg/dL.
  • Maintain HDL cholesterol above 50 mg/dL.
  • Keep triglycerides below 150 mg/dL.
Care plan 08-Apr-1981 -
Dialysis care plan 12-Feb-1976 -
Diabetes self management plan 16-May-1965 Prediabetes
  • Patient will implement and maintain a diabetes self-management plan to prevent progression to type 2 diabetes, including dietary changes, increased physical activity, and regular blood glucose monitoring.
Lifestyle education regarding hypertension 23-Apr-1961 Essential hypertension (disorder)
  • Patient will demonstrate understanding of recommended lifestyle changes to manage blood pressure, including dietary sodium reduction, regular physical activity, weight management, and medication adherence.
  • Achieve and maintain blood pressure below 130/80 mmHg as per current guidelines.
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 2025-05-04 2024-04-28
Body Height 155.4 cm 155.4 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 2 {score} 3 {score}
Body Weight 66.4 kg 66.4 kg
Body mass index (BMI) [Ratio] 27.5 kg/m2 27.5 kg/m2
Diastolic Blood Pressure 75 mm[Hg] 77 mm[Hg]
Systolic Blood Pressure 104 mm[Hg] 108 mm[Hg]
Heart rate 61 /min 76 /min
Respiratory rate 14 /min 13 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 04-MAY-2025 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 3.9 L 4 - 6 %
Glucose [Mass/volume] in Blood 68.9 L 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 17.9 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 0.4 L 0.5 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 10.2 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 136.8 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.5 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 102.8 98 - 108 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 20.0 L 22 - 29 mmol/L

Device Use

Device Date (since)
Blood glucose meter (physical object) 16-May-1965