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

Patient
Name: Campoy, Esperanza
DOB: 13-FEB-1938 (Age: 87)
Gender: female
ID: 4774-795489-0 (ECI)
Author
Dr. Ping, Hel
Patient summary Document
European Patient Summary
Report Date: 28-JAN-2025

Problem list

Condition Onset Date Status
Proteinuria due to type 2 diabetes mellitus 06-Nov-2018 active
Atrial fibrillation 24-May-2016 active
Osteoporosis 01-Dec-2015 active
Microalbuminuria due to type 2 diabetes mellitus 25-Nov-2014 active
Ischemic heart disease 27-Oct-2009 active
Disorder of kidney due to diabetes mellitus 17-Sep-2002 active
Essential hypertension 31-Aug-1999 active
Hypertriglyceridemia 31-Aug-1999 active
Type 2 diabetes mellitus 25-Aug-1998 active
Metabolic syndrome X 25-Aug-1998 active
Hyperlipidemia 19-Aug-1997 active
Impacted molars 02-Apr-1995 active
Sleep apnea 17-Jun-1993 active
Sleep disorder 27-May-1993 active
Anemia 29-Aug-1972 active
Prediabetes 26-Aug-1969 active

Medication list

No known medications

Immunizations list

Vaccine Date
Influenza virus antigen only vaccine product 21-Jan-2025
SARS-CoV-2 mRNA vaccine 02-Mar-2021
Clostridium tetani toxoid antigen adsorbed only vaccine product 15-Nov-2016

Procedure History list

Procedure Date Reason
Pre-discharge assessment 11-Aug-2024 -
Discharge from skilled nursing facility (procedure) 11-Aug-2024 -
Nursing care/supplementary surveillance 10-Aug-2024 -
Physical therapy procedure 09-Aug-2024 -
Professional / ancillary services care 08-Aug-2024 -
Occupational therapy 31-Jul-2024 -
Radiography of ankle 27-Jul-2024 -
History AND physical examination 27-Jul-2024 -
Bone immobilization 27-Jul-2024 Fracture of ankle
Initial patient assessment 27-Jul-2024 -
Development of individualized plan of care 27-Jul-2024 -
Transplantation of kidney regime 23-Mar-2023 History of renal transplant (situation)
Transplant of kidney 14-Mar-2023 Awaiting transplantation of kidney (situation)
Pretransplant evaluation of kidney recipient 14-Mar-2023 Awaiting transplantation of kidney (situation)
Assessment of health and social care needs 11-Sep-2018 -
Assessment of anxiety 11-Sep-2018 -
Screening for drug abuse 11-Sep-2018 -
Assessment using Morse Fall Scale 11-Sep-2018 -
Assessment of substance use 11-Sep-2018 -
Suture open wound 01-May-2017 Laceration of foot

Allergies and Intolerances

Allergy/Intolerance Onset Date Status Type Reaction
? active ?

Care Plan

Active Planned Care / Goals Start Date Reason
Dialysis care plan 17-Dec-2021 -
Lifestyle education regarding hypertension 31-Aug-1999 Essential hypertension (disorder)
  • Patient will demonstrate understanding of hypertension, its risks, and recommended lifestyle modifications including diet, exercise, and medication adherence.
  • Maintain systolic blood pressure below 130 mm[Hg].
  • Maintain diastolic blood pressure below 80 mm[Hg].
Hyperlipidemia clinical management plan 09-Sep-1997 Hyperlipidemia
  • Achieve LDL cholesterol below 70 mg/dL to reduce cardiovascular risk.
  • Achieve triglycerides below 150 mg/dL.
  • Maintain HDL cholesterol above 50 mg/dL.
  • Maintain total cholesterol below 200 mg/dL.
Care plan 17-Jun-1993 Sleep apnea (disorder)
  • Reduce the Apnea-Hypopnea Index (AHI) to less than 5 events per hour to improve sleep quality and reduce cardiovascular risk.
  • Improve subjective sleep quality as reported by the patient using a validated sleep quality scale.
Diabetes self management plan 26-Aug-1969 Prediabetes
  • Patient will implement and maintain a diabetes self-management plan to improve glycemic control and reduce risk of diabetes complications.
  • Achieve and maintain HbA1c below 7.0% through lifestyle modification and self-management.
  • Maintain fasting plasma glucose between 80 and 130 mg/dL.
  • Achieve and maintain a healthy weight as part of diabetes self-management plan.
Weight management program 12-Jul-1949 -
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 2025-01-21 2024-01-16
Body Height 173.4 cm 173.4 cm
Pain severity - 0-10 verbal numeric rating [Score] - Reported 3 {score} 3 {score}
Body Weight 85.2 kg 85.2 kg
Body mass index (BMI) [Ratio] 28.3 kg/m2 28.3 kg/m2
Diastolic Blood Pressure 83 mm[Hg] 82 mm[Hg]
Systolic Blood Pressure 114 mm[Hg] 123 mm[Hg]
Heart rate 98 /min 86 /min
Respiratory rate 13 /min 13 /min

Relevant diagnostic tests/laboratory data

Recent Lab Observations 28-JAN-2025 Reference Range Unit
Glucose [Mass/volume] in Blood 117.4 70 - 140 mg/dL
Urea nitrogen [Mass/volume] in Blood 19.8 7 - 20 mg/dL
Creatinine [Mass/volume] in Blood 3.3 H 0.6 - 1.1 mg/dL
Calcium [Mass/volume] in Blood 9.5 8.5 - 10.4 mg/dL
Sodium [Moles/volume] in Blood 137.9 135 - 145 mmol/L
Potassium [Moles/volume] in Blood 5.0 3.5 - 5.1 mmol/L
Chloride [Moles/volume] in Blood 102.2 98 - 108 mmol/L
Carbon dioxide, total [Moles/volume] in Blood 24.1 22 - 29 mmol/L
Protein [Mass/volume] in Serum or Plasma 6.9 6 - 8.2 g/dL
Albumin [Mass/volume] in Serum or Plasma 5.2 H 3.5 - 5 g/dL
Globulin [Mass/volume] in Serum by calculation 2.5 2 - 4 g/L
Bilirubin.total [Mass/volume] in Serum or Plasma 0.4 0.3 - 1.2 mg/dL
Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma 92.3 39 - 141 U/L
Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma 41.6 H 6 - 33 U/L
Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma 19.9 10 - 31 U/L
Cholesterol [Mass/volume] in Serum or Plasma 165.3 0 - 200 mg/dL
Triglyceride [Mass/volume] in Serum or Plasma 181.8 H 10 - 175 mg/dL
Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay 147.2 H 50 - 130 mg/dL
Cholesterol in HDL [Mass/volume] in Serum or Plasma 32.0 L 50 - 100 mg/dL

Device Use

Device Date (since)
Home continuous positive airway pressure unit (physical object) 21-Jan-2025
Respiratory humidifier (physical object) 21-Jan-2025
Blood glucose meter (physical object) 26-Aug-1969