Generated Narrative: Composition IosefaFuimaono-Composition Profile: NZPS-Composition status: Final type: Patient summary Document date: 2023-11-26 09:37:18+1300 author: PractitionerRole Enrolled GP title: New Zealand Patient Summary custodian: Organization Training Database
Losartan potassium 50 mg tablet – 1 tablet daily (oral) Insulin glargine (Lantus) 100 IU/mL – 20 units per day (injection) Dulaglutide 1.5 mg/0.5 mL – 1 injection weekly Metformin – twice daily Amlodipine 5 mg tablet – 1 tablet daily (oral) Aspirin 75 mg – 1 tablet daily (oral) Allopurinol 300 mg tablet – 1 tablet nightly (oral)
Allergies and adverse reactions Document
Diazepam – confirmed allergy. Experienced increased confusion and headaches when prescribed for anxiety and difficulty sleeping.
Fracture of neck of femur (left hip) – onset June 2019 Type 2 diabetes mellitus – onset February 2011, on insulin Gout – onset March 2015 Benign essential hypertension (mild) – onset October 2012
Influenza (Flu 65+) – June 2015 Pneumococcal PCV13 High Risk – July 2015 Influenza (Flu 65+) – June 2019 Tdap adult – June 2019 COVID-19 Comirnaty dose 1 – July 2021 COVID-19 Comirnaty dose 2 – August 2022
Relevant diagnostic tests and/or laboratory data
Results from 5 March 2023: HbA1c: 60 mmol/mol LDL cholesterol: 3.4 mmol/L Total cholesterol: 5.1 mmol/L HDL cholesterol: 1.5 mmol/L
Most recent readings (25 November 2023): Blood pressure: 136/88 mmHg Heart rate: 84 bpm Height: 1.84 m Weight: 104 kg (29 September 2023)
Primary open reduction and internal fixation of left proximal femoral fracture – June 2019. Concussion symptoms ongoing following fall.
Uses a walking frame or electric scooter. Often confused, struggles to communicate in English. Relies on caregiver Cindy for assistance with many activities of daily living. Does not leave the house much. Family arranging transfer to residential care.
Iosefa is a 73-year-old Samoan man who speaks Samoan as his primary language. He lives in Hamilton and relies heavily on his next of kin Cindy Fuimaono. He uses a walking frame or electric scooter to get around and rarely leaves the home. Family is in the process of arranging a transfer to residential care.
No active plan of care recorded.
Ex-smoker. Was smoking 30 packs per year, quit in 2005 (1-9 cigarettes/day, light smoker).
No advance directives recorded.
Generated Narrative: Patient IosefaFuimaono-Patient Profile: NZPS-Patient Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) Active: true Contact Detail ph: 021111111(Mobile) Brooklyn Street Claudelands Hamilton 3214 NZ (home) Language: Samoan Next-of-kin: Cindy Fuimaono ph: 021111111(Mobile) Links: General Practitioner: Dr James Test-Smith Patient Birth Place Samoa <td style="background-color: #f3f5da" title="The ethnic group or groups that a person identifies with or feels they belong to. Ethnicity is a measure of cultural affiliation as opposed to race, ancestry, nationality or citizen. Ethnicity is self-perceived and a person can belong to more than one group.#xA;#xA;The Stats New Zealand standard can be found [here](http://aria.stats.govt.nz/aria/#ClassificationView:uri=http://stats.govt.nz/cms/ClassificationVersion/YVqOcFHSlguKkT17).">NZ Ethnicity Samoan
Generated Narrative: Practitioner DrJamesTestSmith-Practitioner Profile: NZPS-Practitioner active: true name: James Test-Smith
Generated Narrative: PractitionerRole DrJamesTestSmith-PractitionerRole Profile: NZPS-PractitionerRole practitioner: Dr James Test-Smith organization: Organization Training Database code: Enrolled GP
Generated Narrative: Organization TrainingDatabase-Organization Profile: https://fhir-ig.digital.health.nz/nzps/StructureDefinition/nzps-organization identifier: HPIFacility/F99820-C (use: official, ) active: true name: Training Database
Generated Narrative: Condition NeckOfFemurFracture-Condition Profile: NZPS-Problem (Condition) Long Term Condition Indicator: true clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Fracture of neck of femur subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) onset: 2019-06-08 recordedDate: 2023-11-26 09:58:31+1300 recorder: Dr James Test-Smith note: Left hip fracture
Generated Narrative: Condition Type2Diabetes-Condition Profile: NZPS-Problem (Condition) Long Term Condition Indicator: true clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Type 2 diabetes mellitus subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) onset: 2011-02-05 recordedDate: 2023-11-26 10:02:45+1300 recorder: Dr James Test-Smith note: On insulin
Generated Narrative: Condition Gout-Condition Profile: NZPS-Problem (Condition) Long Term Condition Indicator: true clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Gout subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) onset: 2015-03-18 recordedDate: 2023-11-26 10:05:13+1300 recorder: Dr James Test-Smith
Generated Narrative: Condition Hypertension-Condition Profile: NZPS-Problem (Condition) Long Term Condition Indicator: true clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item severity: Mild code: Benign essential hypertension subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) onset: 2012-10-24 recordedDate: 2023-11-26 10:07:25+1300 recorder: Dr James Test-Smith
Generated Narrative: Condition HipFractureRepair-Condition Profile: NZPS-Problem (Condition) Long Term Condition Indicator: true clinicalStatus: Resolved verificationStatus: Confirmed category: Problem List Item code: Primary open reduction and internal fixation of proximal femoral fracture subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) onset: 2019-06-08 recordedDate: 2023-11-26 10:24:06+1300 recorder: Dr James Test-Smith note: Left femur fracture. Concussion symptoms still ongoing following fall in 2019.
Open reduction of fracture with internal fixation
Primary open reduction and internal fixation of proximal femoral fracture
Left femur fracture. Concussion symptoms still ongoing following fall in 2019.
Generated Narrative: Condition WalkingAid-Condition Profile: NZPS-Problem (Condition) Long Term Condition Indicator: true clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Walking aid use subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) onset: 2019-06-30 recordedDate: 2023-11-26 10:29:07+1300 recorder: Dr James Test-Smith note: Uses a walker or scooter
Generated Narrative: MedicationStatement Losartan-MedicationStatement Profile: NZPS-MedicationStatement NZePS Long Term Medication Indicator: true status: Active medication: Losartan potassium 50 mg tablet subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) dateAsserted: 2023-11-25 informationSource: Dr James Test-Smith Dosages - Text Route * 1 tablet daily Oral route
Generated Narrative: MedicationStatement InsulinGlargine-MedicationStatement Profile: NZPS-MedicationStatement NZePS Long Term Medication Indicator: true status: Active medication: Lantus – insulin glargine 100 IU/mL injection, 3 mL cartridge subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) dateAsserted: 2023-11-25 informationSource: Dr James Test-Smith Dosages - Text Route * 20 units per day Subcutaneous route
Insulin glargine 100 units/mL injection, 3 mL cartridge
Lantus – insulin glargine 100 IU/mL injection, 3 mL cartridge
Generated Narrative: MedicationStatement Dulaglutide-MedicationStatement Profile: NZPS-MedicationStatement NZePS Long Term Medication Indicator: true status: Active medication: Dulaglutide 1.5 mg/0.5 mL injection pen subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) dateAsserted: 2023-11-25 informationSource: Dr James Test-Smith Dosages - Text Route * 1 injection every week Subcutaneous route
Dulaglutide 1.5 mg/0.5 mL injection, pen
Generated Narrative: MedicationStatement Metformin-MedicationStatement Profile: NZPS-MedicationStatement NZePS Long Term Medication Indicator: true status: Active medication: Metformin subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) dateAsserted: 2023-11-25 informationSource: Dr James Test-Smith Dosages - Text Route * Twice daily – 1 in morning and 1 at night Oral route
Twice daily – 1 in morning and 1 at night
Generated Narrative: MedicationStatement Amlodipine-MedicationStatement Profile: NZPS-MedicationStatement NZePS Long Term Medication Indicator: true status: Active medication: Amlodipine 5 mg tablet subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) dateAsserted: 2023-11-25 informationSource: Dr James Test-Smith Dosages - Text Route * 1 tablet daily Oral route
Generated Narrative: MedicationStatement Aspirin-MedicationStatement Profile: NZPS-MedicationStatement NZePS Long Term Medication Indicator: true status: Active medication: Aspirin 75 mg tablet subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) dateAsserted: 2023-11-25 informationSource: Dr James Test-Smith Dosages - Text Route * 1 tablet daily – 75 mg Oral route
Generated Narrative: MedicationStatement Allopurinol-MedicationStatement Profile: NZPS-MedicationStatement NZePS Long Term Medication Indicator: true status: Active medication: Allopurinol 300 mg tablet subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) dateAsserted: 2023-11-25 informationSource: Dr James Test-Smith Dosages - Text Route * 1 tablet nightly Oral route
Generated Narrative: AllergyIntolerance Diazepam-AllergyIntolerance Profile: NZPS-AllergyIntolerance clinicalStatus: Active verificationStatus: Confirmed code: Diazepam patient: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) onset: 2023-11-26 recordedDate: 2023-11-26 10:34:09+1300 recorder: Dr James Test-Smith note: Prescribed diazepam for anxiety and difficulty sleeping. Experienced increased confusion and headaches, which went away after stopping the drug.
Prescribed diazepam for anxiety and difficulty sleeping. Experienced increased confusion and headaches, which went away after stopping the drug.
Generated Narrative: Immunization FluVaccine2015-Immunization Profile: NZPS-Immunization status: Completed vaccineCode: Influenza patient: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) occurrence: 2015-06-01 recorded: 2015-06-01 lotNumber: P9076556 site: Left Arm route: Injection, intramuscular Performers - Function Actor * Administering Provider Dr James Test-Smith
Generated Narrative: Immunization PCV13-Immunization Profile: NZPS-Immunization status: Completed vaccineCode: Pneumococcal conjugate vaccine, 13 valent patient: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) occurrence: 2015-07-01 recorded: 2015-07-01 lotNumber: U456789 site: Right Arm route: Injection, intramuscular Performers - Function Actor * Administering Provider Dr James Test-Smith
Pneumococcal 13-valent conjugate vaccine
Pneumococcal conjugate vaccine, 13 valent
Generated Narrative: Immunization FluVaccine2019-Immunization Profile: NZPS-Immunization status: Completed vaccineCode: Influenza patient: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) occurrence: 2019-06-01 recorded: 2019-06-01 lotNumber: Y789T75 site: Left Arm route: Injection, intramuscular Performers - Function Actor * Administering Provider Dr James Test-Smith
Generated Narrative: Immunization TdapAdult-Immunization Profile: NZPS-Immunization status: Completed vaccineCode: Diphtheria adult dosage, Tetanus, acellular Pertussis patient: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) occurrence: 2019-06-08 recorded: 2019-06-08 lotNumber: 12345 site: Left Arm route: Injection, intramuscular Performers - Function Actor * Administering Provider Dr James Test-Smith
Vaccine product containing only Bordetella pertussis and Clostridium tetani and Corynebacterium diphtheriae antigens
Diphtheria adult dosage, Tetanus, acellular Pertussis
Generated Narrative: Immunization COVID19Dose1-Immunization Profile: NZPS-Immunization status: Completed vaccineCode: COVID-19 Comirnaty (Pfizer/BioNTech) patient: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) occurrence: 2021-07-14 recorded: 2021-07-14 lotNumber: 2907888 site: Left Arm route: Injection, intramuscular Performers - Function Actor * Administering Provider Dr James Test-Smith note: Dose 1
Generated Narrative: Immunization COVID19Dose2-Immunization Profile: NZPS-Immunization status: Completed vaccineCode: COVID-19 Comirnaty (Pfizer/BioNTech) patient: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) occurrence: 2022-08-04 recorded: 2022-08-04 lotNumber: 56789 site: Right Arm route: Injection, intramuscular Performers - Function Actor * Administering Provider Dr James Test-Smith note: Dose 2
Generated Narrative: Observation HbA1c-Observation Profile: NZPS-Observation-Results-Laboratory-Pathology status: Final category: Laboratory code: HbA1c subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-03-05 10:46:20+1300 performer: Dr James Test-Smith value: 60 mmol/mol (Details: UCUM codemmol/mol = 'mmol/mol')
Hemoglobin A1c/Hemoglobin.total in Blood
Generated Narrative: Observation LDL-Observation Profile: NZPS-Observation-Results-Laboratory-Pathology status: Final category: Laboratory code: LDL cholesterol subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-03-05 10:46:24+1300 performer: Dr James Test-Smith value: 3.4 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
LDL Cholesterol [Mass/volume] in Serum or Plasma by Direct assay
Generated Narrative: Observation TotalCholesterol-Observation Profile: NZPS-Observation-Results-Laboratory-Pathology status: Final category: Laboratory code: Total cholesterol subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-03-05 10:46:26+1300 performer: Dr James Test-Smith value: 5.1 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
Cholesterol [Mass/volume] in Serum or Plasma
Generated Narrative: Observation HDL-Observation Profile: NZPS-Observation-Results-Laboratory-Pathology status: Final category: Laboratory code: HDL cholesterol subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-03-05 10:46:27+1300 performer: Dr James Test-Smith value: 1.5 mmol/L (Details: UCUM codemmol/L = 'mmol/L')
HDL Cholesterol [Mass/volume] in Serum or Plasma
High density lipoprotein cholesterol measurement
Generated Narrative: Observation BloodPressure-Observation Profiles: NZPS-Observation-Vital-Signs, Observation Blood Pressure Profile status: Final category: Vital Signs code: Blood pressure subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-11-25 14:20:33+1300 performer: Dr James Test-Smith component code: Systolic blood pressure value: 136 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]') component code: Diastolic blood pressure value: 88 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
Blood pressure panel with all children optional
Generated Narrative: Observation HeartRate-Observation Profiles: NZPS-Observation-Vital-Signs, Observation Heart Rate Profile status: Final category: Vital Signs code: Heart rate subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-11-25 14:20:11+1300 performer: Dr James Test-Smith value: 84 beats/minute (Details: UCUM code/min = '/min')
Generated Narrative: Observation BodyHeight-Observation Profiles: NZPS-Observation-Vital-Signs, Observation Body Height Profile status: Final category: Vital Signs code: Body height subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-11-25 14:21:02+1300 performer: Dr James Test-Smith value: 184 cm (Details: UCUM codecm = 'cm')
Generated Narrative: Observation BodyWeight-Observation Profiles: NZPS-Observation-Vital-Signs, Observation Body Weight Profile status: Final category: Vital Signs code: Body weight subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-09-29 performer: Dr James Test-Smith value: 104 kg (Details: UCUM codekg = 'kg')
Generated Narrative: Observation SmokingStatus-Observation Profile: NZPS-Observation-Smoking-Status status: Final category: Social History code: Tobacco smoking status subject: Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, )) effective: 2023-11-26 performer: Dr James Test-Smith value: Ex-smoker note: Was smoking 30 packs per year, quit in 2005. Previously 1-9 cigarettes per day (light smoker).
Was smoking 30 packs per year, quit in 2005. Previously 1-9 cigarettes per day (light smoker).