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

Patient
Name: Tavares, Gabriela
DOB: 26-FEB-1947 (Age: 78)
Gender: female
ID: 8337-229151-4 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 16-SEP-2024

Problem list

Condition Onset Date Status
Ischemic heart disease 27-Jul-2015 active
Acute non-ST segment elevation myocardial infarction 06-Nov-2012 active
Obstructive sleep apnea syndrome 25-Apr-2001 active
Sleep disorder 19-Mar-2001 active
Anemia 20-Apr-1998 active
Osteoarthritis of knee 22-Jul-1997 active
Prediabetes 14-Apr-1997 active
Chronic sinusitis 24-Oct-1995 active
Recurrent urinary tract infection 01-Sep-1960 active

Medication list

No known medications

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 16-Sep-2024
SARS-CoV-2 mRNA vaccine 12-Apr-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 01-Aug-2016

Procedure History list

Procedure Date Reason
Radiography of ankle 11-Apr-2022 -
Bone immobilization 11-Apr-2022 Fracture of ankle
Bone density scan 11-Apr-2022 Fracture of ankle
Postoperative procedure education 20-Aug-2015 History of coronary artery bypass grafting (situation)
Stair-climbing test 20-Aug-2015 History of coronary artery bypass grafting (situation)
Walking exercise test 20-Aug-2015 History of coronary artery bypass grafting (situation)
Discharge to ward 20-Aug-2015 -
Discharge from hospital 20-Aug-2015 History of coronary artery bypass grafting (situation)
Electrocardiographic procedure 19-Aug-2015 -
Transfusion of packed red blood cells 19-Aug-2015 -
Plain X-ray of chest 19-Aug-2015 -
Removal of endotracheal tube 18-Aug-2015 -

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
Aspirin 1946-02-24 active medication Abdominal pain (finding)
Lisinopril 1946-02-24 active medication Cough (finding)
Grass pollen 1946-02-24 active environment
Soyabean 1946-02-24 active food Diarrhea (finding)
Allergy to substance 1946-02-24 active environment

Care Plan

Active Planned Care / Goals Start Date Reason
Discharge care plan 07-Nov-2012 -
Care plan 25-Apr-2001 Obstructive sleep apnea syndrome (disorder)
  • Reduce the apnea-hypopnea index (AHI) to less than 5 events per hour to improve sleep quality and reduce cardiovascular risk.
  • Patient reports improved sleep quality and reduced daytime sleepiness as measured by the Epworth Sleepiness Scale (ESS) score less than 10.
  • Patient uses CPAP device for at least 4 hours per night on 70% of nights.
Musculoskeletal care 22-Jul-1997 Osteoarthritis of knee
  • Reduce knee pain severity to improve mobility and quality of life
  • Increase ability to walk without assistance
  • Decrease swelling and inflammation in the affected knee
Diabetes self management plan 14-Apr-1997 Prediabetes
  • Patient will demonstrate understanding of prediabetes and implement recommended lifestyle modifications including diet, exercise, and blood glucose monitoring.
  • Maintain or achieve hemoglobin A1c below 6.5% to reduce risk of progression to diabetes.
  • Achieve at least 5% reduction in body weight through dietary changes and increased physical activity.
  • Engage in at least 150 minutes of moderate-intensity physical activity per week.
Self-care interventions 09-Feb-1946 -
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 2024-09-16 2023-09-11
Body Height 168.1 cm 168.1 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 1 {score} 0 {score}
Body Weight 78.7 kg 78.7 kg
Body mass index (BMI) [Ratio] 27.9 kg/m2 27.9 kg/m2
Diastolic Blood Pressure 69 mm[Hg] 69 mm[Hg]
Systolic Blood Pressure 110 mm[Hg] 107 mm[Hg]
Heart rate 74 /min 74 /min
Respiratory rate 14 /min 14 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 16-SEP-2024 Reference Range Unit
Hemoglobin A1c/Hemoglobin.total in Blood 6.2 4.5 - 6.4 %
Glucose [Mass/volume] in Blood 95.9 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 19.8 7 - 30 mg/dL
Creatinine [Mass/volume] in Blood 0.8 0.5 - 1.3 mg/dL
Calcium [Mass/volume] in Blood 9.2 8.6 - 10.2 mg/dL
Sodium [Moles/volume] in Blood 136.8 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 4.4 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 103.9 98 - 114 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 27.3 22 - 32 mmol/L

Device Use

Device Date (since)
Home continuous positive airway pressure unit (physical object) 16-Sep-2024
Respiratory humidifier (physical object) 16-Sep-2024
Walker (physical object) 22-Jul-1997
Blood glucose meter (physical object) 14-Apr-1997
Home nebulizer (physical object) 24-Oct-1995