Generated Narrative: Composition 24c0f4df-ed5c-4a81-b34f-6d7cfffe310b
Profile: Composition (EPS)
identifier: urn:ietf:rfc:9562/4efe560e-aeef-4419-9a57-4b6af5c05779
status: Final
type: Patient summary Document
date: 2025-08-31 17:46:55+0000
author: PractitionerRole
title: European Patient Summary
confidentiality: normal
custodian: Organization BfA-Klinik
| Condition | Onset Date | Status |
|---|---|---|
| Hyperlipidemia | 2020-06-15 | active |
| Emphysematous bronchitis | 2020-06-15 | active |
| Ischemic heart disease | 2010-04-19 | active |
| Chronic sinusitis | 1994-01-16 | active |
| Anemia | 1993-02-22 | active |
| Prediabetes | 1991-02-18 | active |
| Medication | Since | Form | Dosage | Reason |
|---|---|---|---|---|
| Simvastatin 10 mg oral tablet | 2025-07-15 | Oral tablet | 1 tablet (10 mg) by mouth once daily | Hyperlipidemia |
| Albuterol (as albuterol sulfate) 5 mg/mL solution for inhalation | 2025-07-14 | Solution for inhalation | 2.5 mg (0.5 mL of 5 mg/mL solution) via nebulizer every 4 to 6 hours as needed | Chronic obstructive bronchitis (disorder) |
| Acetaminophen 300 mg and hydrocodone bitartrate 5 mg oral tablet | 2025-07-14 | Oral tablet | 1 tablet (300 mg/5 mg) by mouth every 4 to 6 hours as needed for pain | |
| 60 ACTUAT Fluticasone propionate 0.25 MG/ACTUAT / salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler | 2025-07-14 | 1 inhalation (0.25 mg/0.05 mg) twice daily | Chronic obstructive bronchitis (disorder) | |
| Clopidogrel (as clopidogrel bisulfate) 75 mg oral tablet | 2010-04-26 | Oral tablet | 1 tablet (75 mg) by mouth once daily | |
| Simvastatin 20 mg oral tablet | 2010-04-26 | Oral tablet | 1 tablet (20 mg) by mouth once daily | |
| Nitroglycerin 400 microgram/actuation sublingual spray | 2010-04-26 | Sublingual spray | 400 micrograms (1 spray) sublingually 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 | 2010-04-26 | Prolonged-release oral tablet | 1 tablet (100 mg) once daily | |
| doxycycline hyclate 100 MG | 2008-08-12 | 100 mg twice daily | Viral sinusitis (disorder) | |
| Astemizole 10 mg oral tablet | 1978-10-26 | Oral tablet | 1 tablet (10 mg) once daily | |
| Hydrocortisone 10 mg/g and urea 100 mg/g cutaneous cream | 1978-10-11 | Cutaneous cream | Apply a thin layer (approximately 1 g) to the affected area twice daily | Contact dermatitis |
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 2025-07-14 |
| SARS-CoV-2 mRNA vaccine | 2021-03-01 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 2018-06-04 |
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| Penicillin V | 1978-10-26 | active | medication | |
| Allergy to substance | 1978-10-26 | active | environment |
| Immunization Recommendation | Due Date | Reason |
|---|---|---|
| Vaccine product containing only Influenza virus antigen (medicinal product) | 2025-10-01 | Annual seasonal influenza vaccination |
| No known procedures |
| Vital Signs | 2025-07-14 | 2024-07-08 |
|---|---|---|
| Body Height | 158.3 cm | 158.3 cm |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 3 {score} | 2 {score} |
| Body Weight | 73.3 kg | 71.3 kg |
| Body mass index (BMI) [Ratio] | 29.2 kg/m2 | 28.5 kg/m2 |
| Diastolic Blood Pressure | 55 mm[Hg] | 62 mm[Hg] |
| Systolic Blood Pressure | 113 mm[Hg] | 104 mm[Hg] |
| Heart rate | 80 /min | 72 /min |
| Respiratory rate | 13 /min | 14 /min |
| Recent Lab Observations | 15 Jul 2024 | Reference Range | Unit |
|---|---|---|---|
| Glucose [Mass/volume] in Blood | 65.9 L | 70 - 99 | mg/dL |
| Urea nitrogen [Mass/volume] in Blood | 9.2 | 7 - 20 | mg/dL |
| Creatinine [Mass/volume] in Blood | 2.7 H | 0.6 - 1.3 | mg/dL |
| Calcium [Mass/volume] in Blood | 8.7 | 8.5 - 10.3 | mg/dL |
| Sodium [Moles/volume] in Blood | 136.4 | 135 - 145 | mmol/L |
| Potassium [Moles/volume] in Blood | 4.4 | 3.5 - 5.1 | mmol/L |
| Chloride [Moles/volume] in Blood | 101.2 | 98 - 108 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Blood | 28.5 | 22 - 32 | mmol/L |
| Protein [Mass/volume] in Serum or Plasma | 6.9 | 6 - 8.3 | g/dL |
| Albumin [Mass/volume] in Serum or Plasma | 4.0 | 3.5 - 5 | g/dL |
| Globulin [Mass/volume] in Serum by calculation | 2.9 | 2 - 3.5 | g/L |
| Bilirubin.total [Mass/volume] in Serum or Plasma | 0.8 | 0.3 - 1.2 | mg/dL |
| Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma | 87.0 | 35 - 117 | U/L |
| Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma | 45.0 | 7 - 46 | U/L |
| Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma | 8.7 L | 10 - 40 | U/L |
| Cholesterol [Mass/volume] in Serum or Plasma | 193.2 | 125 - 200 | mg/dL |
| Triglyceride [Mass/volume] in Serum or Plasma | 149.3 | 0 - 199 | mg/dL |
| Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay | 129.5 | 0 - 159 | mg/dL |
| Cholesterol in HDL [Mass/volume] in Serum or Plasma | 62.7 | 50 - 100 | mg/dL |
| Device | Date (since) |
|---|---|
| Home nebulizer (physical object) | 2021-06-21 |
| Blood glucose meter (physical object) | 1991-02-18 |