Generated Narrative: Composition b9dc409d-ec81-4556-9fac-4dc3f731c199 Profile: Composition (HDR) status: Final type: Hospital Discharge summary encounter: Encounter: status = finished; class = inpatient encounter (ActCode#IMP); serviceType = Diabetes mellitus screening (procedure); period = 2025-04-01 08:45:00+0000 --> 2025-04-10 11:00:00+0000; reasonCode = Prediabetes (finding) date: 2025-04-29 13:30:00+0100 author: PractitionerRole title: Hospital Discharge Report custodian: Organization Casa di cura Villa S. Giuliana
Mr. Luigi De Luca, a 57-year-old male, was admitted on 1st April following a pre-diabetic episode characterized by episodes of fatigue, polyuria, and increased thirst. Recent routine blood tests showed elevated fasting blood glucose and HbA1c levels that required further investigation. When Mr De Luca arrived in the morning we recorded a fasting blood glucose level at 180 mg/dL. His HbA1c level was 7.8%. He seemed to be dehydrated, so that he immediately was sent to the ward for a full breakfast and fluid substitution.
Mr. Luigi has a family history of diabetes (type 2, mother and maternal grandmother).
Vital signs 1st April 10th April Body weight 109 kg 108 kg Body height 177 cm Blood Pressure 155 / 95 mmHg 150 / 90 mmHg
The patient smokes "a few" cigarettes per day.
During the hospital stay from 1 to 10 April, Mr. De Luca underwent a series of diagnostic tests, consultations and initial treatment. Throughout his hospital stay, Mr. De Luca was monitored closely. His blood sugar levels improved modestly with the introduction of Metformin, and no acute complications were observed.
Relevant diagnostic tests/laboratory data note
Blood Glucose Monitoring Regular monitoring of fasting blood glucose levels and random blood glucose levels. Fasting glucose levels consistently ranged between 140-180 mg/dL. Date Fasting glucose [Moles/volume] in Blood Range 1 April 2025 180 mg/dL 70 to 99 mg/dL 2 April 2025 140 mg/dL 70 to 99 mg/dL 3 April 2025 150 mg/dL 70 to 99 mg/dL 5 April 2025 140 mg/dL 70 to 99 mg/dL HbA1c Test: An HbA1c level of 7.2%, confirming the diagnosis of Type 2 Diabetes Mellitus. Date Hemoglobin A1c [Mass/volume] in Blood Range 1 April 2025 7.2% < 5.7% Oral Glucose Tolerance Test (OGTT): This test further confirmed impaired glucose tolerance. Date Glucose [Mass/volume] in Serum or Plasma --1 hour post dose glucose Range 2 April 2025 180 mg/dL 70 to 99 mg/dL
Lifestyle Consultation: Mr. De Luca met with a dietitian to discuss necessary changes in his diet, focusing on a low glycemic index diet and the need to monitor carbohydrate intake. He was also advised to engage in regular physical activity. Diabetes Education: Mr. De Luca attended educational sessions on diabetes management, including the importance of regular blood sugar monitoring, recognizing hypoglycemia and hyperglycemia symptoms, and foot care. Starting Pharmacotherapy with Metformin.
Metformin 500 mg twice daily was started as the first-line treatment to help control blood glucose levels. Medication administrations Dose/Frequency SNOMED Metformin, oral tbl 500 mg, twice / day 765507008 Multivitamines daily
Follow-up Activity SNOMED Endocrinology Clinic Follow-up appointment in 2 weeks to assess response to treatment 306118006 Referral to endocrinology service (procedure) Dietitian Consultation Appointment in 1 month for further dietary planning 103699006 Referral to dietitian (procedure) Routine Blood tests Repeat HbA1c in 3 months 43396009 Hemoglobin A1c measurement (procedure)
Discharge Diagnoses Codes Type 2 Diabetes Mellitus – Newly diagnosed. Type 2 diabetes mellitus E11 (ICD-10) Diabetes mellitus type 2 (disorder) 44054006 (SNOMED)
Instructions at Discharge to Mr. De Luca Continue home glucose monitoring and to maintain a log for review at follow-up appointments. Continue with the prescribed medication and lifestyle changes. Monitor blood sugar levels at home regularly. Adhere to the diabetic diet plan. Stay physically active, with at least 30 minutes of moderate exercise most days of the week. Return to the emergency department for any signs of hyperglycemia (e.g., excessive thirst, urination, confusion) or hypoglycemia (e.g., sweating, shakiness, confusion).
Generated Narrative: Patient b01a2623-e219-41d2-8e78-1fa1439751d0 Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) Other Id: Medical record number/8121c77e7bf9 Contact Detail +39 0334 8920354 Via Zannoni 29 Serso 38057 Italy (home)
Generated Narrative: Encounter 7c9a2bf1-507f-4d43-b06e-d78e9670379d Profile: Encounter (HDR) status: finished class: ActCode: IMP (inpatient encounter) serviceType: Diabetes mellitus screening (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) period: 2025-04-01 08:45:00+0000 --> 2025-04-10 11:00:00+0000 reasonCode: Prediabetes (finding) serviceProvider: Organization Casa di cura Villa S. Giuliana
Generated Narrative: PractitionerRole 74403dd8-bb1b-45f9-bb69-e843dfaf45e9 practitioner: Practitioner Augusto Zucchero-Combattente organization: Organization Casa di cura Villa S. Giuliana
Generated Narrative: Practitioner 0710d9e7-3f1a-4e16-a9b3-5c991fe23c95 name: Augusto Zucchero-Combattente telecom: augusto@casasgiuliana.osp.venetia.it
Generated Narrative: Condition a5bf69e4-24db-48a8-9eda-71516dcaf1d9 Profile: Condition (EU core) clinicalStatus: Active code: Type 2 diabetes mellitus subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) onset: 2025-04-04
Generated Narrative: CarePlan b84038f8-9541-4c5b-93b0-a7f1b8e55bd3 Profile: Care Plan (HDR) status: Active intent: Plan category: Diabetes clinical management plan title: Diabetes Management Plan subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) period: 2025-04-10 --> (ongoing) activity Details - Code Status * Referral to endocrinology service Not Started activity Details - Code Status * Referral to dietitian Not Started activity Details - Code Status * Hemoglobin A1c measurement Not Started
Generated Narrative: Procedure 92ffc1fd-71ff-4d54-bc06-25d9e1e1fea0 Profile: Procedure (EU core) status: Completed code: Lifestyle education (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) performed: 2025-04-05
Generated Narrative: Procedure a74a3dca-92fa-4b71-8e70-89a07ac74bc3 Profile: Procedure (EU core) status: Completed code: Diabetic education (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) performed: 2025-04-04
Generated Narrative: Procedure 53a8c3c3-5d1b-4950-87bc-fddae2ebc079 Profile: Procedure (EU core) status: In Progress code: Metformin therapy (procedure) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) performed: 2025-04-04
Generated Narrative: FamilyMemberHistory 635c22e7-d7f1-45ad-9b4d-d4fe35239085 status: Completed patient: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) relationship: mother Conditions - Code * Family history of diabetes mellitus type 2 (situation)
Family history of diabetes mellitus type 2 (situation)
Generated Narrative: FamilyMemberHistory 3fbdfbe1-9d70-47ec-ac05-3e30b063365a status: Completed patient: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) relationship: maternal grandmother Conditions - Code * Family history of diabetes mellitus type 2 (situation)
Generated Narrative: Observation f0113857-b9b7-429b-8893-b645a38ae20a status: Final category: Vital Signs code: Body weight subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 value: 109 kg (Details: UCUM codekg = 'kg')
Generated Narrative: Observation 065c918f-730a-47f8-938a-7ad54618037b status: Final category: Vital Signs code: Body weight subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-19 value: 108 kg (Details: UCUM codekg = 'kg')
Generated Narrative: Observation 81783ae4-c36d-424f-8cea-fe7d3407a36b status: Final category: Vital Signs code: Body height subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 value: 177 cm (Details: UCUM codecm = 'cm')
Generated Narrative: Observation a19e48e1-2271-4cdb-9c76-b0626c7a5363 status: Final category: Vital Signs code: Blood pressure panel with all children optional subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 component code: Systolic blood pressure value: 155 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') component code: Diastolic blood pressure value: 95 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
Blood pressure panel with all children optional
Generated Narrative: Observation fd7f7580-5788-45dd-88ec-dca615d69c7d status: Final category: Vital Signs code: Blood pressure panel with all children optional subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-10 component code: Systolic blood pressure value: 150 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') component code: Diastolic blood pressure value: 90 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
Generated Narrative: Observation 67152b1b-0ffa-4b8f-8b6a-a3d71d4d58b6 status: Final category: Social History code: History of Tobacco use subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-01 value: Current smoker note: Patient smokes a few cigarettes a day
Generated Narrative: MedicationAdministration bda0b497-c9f2-47ca-8339-da1d379cb2f4 Profile: MedicationAdministration (HDR) status: In Progress medication: Product containing precisely metformin hydrochloride 500 milligram/1 each prolonged-release oral tablet (clinical drug) subject: Luigi De Luca Male, DoB: 1966-09-30 ( National unique individual identifier) effective: 2025-04-03 --> (ongoing) Dosages - Text Route Dose * 500 mg, twice a day Oral route 500 mg
Product containing precisely metformin hydrochloride 500 milligram/1 each prolonged-release oral tablet (clinical drug)