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

Patient
Name: Koch II, Ruben
DOB: 19-MAY-1981 (Age: 44)
Gender: male
ID: 2300-351474-4 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 08-APR-2025

Problem list

Condition Onset Date Status
Essential hypertension 26-Jan-2021 active
Hyperglycemia 21-Jan-2020 active
Anemia 21-Jan-2020 active
Hypertriglyceridemia 21-Jan-2020 active
Type 2 diabetes mellitus 14-Jan-2020 active
Metabolic syndrome X 14-Jan-2020 active

Medication list

No known medications

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 08-Apr-2025
SARS-CoV-2 mRNA vaccine 13-Apr-2021
Hepatitis A virus antigen only vaccine product 14-Jan-2020
Clostridium tetani toxoid antigen adsorbed only vaccine product 14-Jan-2020

Procedure History list

Procedure Date Reason
Suture open wound 01-Nov-2021 Laceration of foot

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
? active ?

Care Plan

Active Planned Care / Goals Start Date Reason
Respiratory therapy 15-Apr-2025 -
Lifestyle education regarding hypertension 26-Jan-2021 Essential hypertension (disorder)
  • Maintain blood pressure below 130/80 mmHg through lifestyle modification
  • Reduce body weight to target BMI less than 25 kg/m2
  • Limit daily sodium intake to less than 2.3 grams
  • Engage in at least 150 minutes of moderate-intensity aerobic activity per week
Diabetes self management plan 14-Jan-2020 Diabetes mellitus type 2 (disorder)
  • Patient will demonstrate understanding and application of diabetes self-management, including blood glucose monitoring, medication adherence, diet, and physical activity.
  • Achieve and maintain HbA1c at individualized target level.
  • Maintain fasting blood glucose within recommended range.
  • Patient will check and record blood glucose as recommended by care team.

Vital Signs

Vital Signs 2025-04-08 2025-02-18
Body Height 176.5 cm 176.5 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 1 {score}
Body Weight 92.9 kg 92.7 kg
Body mass index (BMI) [Ratio] 29.8 kg/m2 29.8 kg/m2
Diastolic Blood Pressure 87 mm[Hg] 90 mm[Hg]
Systolic Blood Pressure 141 mm[Hg] 140 mm[Hg]
Heart rate 67 /min 98 /min
Respiratory rate 14 /min 15 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 08-APR-2025 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 6.0 4.5 - 6.4 %
Glucose [Mass/volume] in Blood 93.5 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 16.0 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 1.2 0.9 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.4 8.5 - 10.5 mg/dL
Sodium [Moles/volume] in Blood 143.8 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 5.2 H 3.5 - 5 mmol/L
Chloride [Moles/volume] in Blood 106.5 98 - 107 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 23.3 22 - 32 mmol/L
Cholesterol [Mass/volume] in Serum or Plasma 124.8 L 125 - 200 mg/dL
Triglyceride [Mass/volume] in Serum or Plasma 114.2 40 - 150 mg/dL
Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay 70.5 0 - 130 mg/dL
Cholesterol in HDL [Mass/volume] in Serum or Plasma 31.5 L 40 - 60 mg/dL
Microalbumin/Creatinine [Mass Ratio] in Urine 15.6 0 - 30 mg/g

Device Use

Device Date (since)
Blood glucose meter (physical object) 14-Jan-2020