Doctor view · 2-minute read
Lata Deshpande 67 F
Dadar West, Mumbai · Referred by Dr. S. Kulkarni (Cardiologist (fictional))
Allergy: No known drug allergiesApproved 25 Oct 2026
Summary
67 F, post-MI (LAD stent 2023), HTN well controlled (home 126/76). LDL 68 at target. New: eGFR down (~57), K 5.3 on ramipril, TSH 6.8 (subclinical hypothyroidism), Hb 11.6 with low MCV.
AI-drafted from structured data → edited and approved by the doctor
Red flags & open actions
Rule thresholds pending Dr. Kajal- 1Kidney filtering: reduced — eGFR 58 mL/min/1.73m² (was 63)Lab 22 Oct
- 2Thyroid control hormone: high — TSH Ultrasensitive 6.8 µIU/mL (was 4.9)Lab 22 Oct
- 33-month sugar average: prediabetes range — HbA1c 5.8 % (was 5.7)Lab 22 Oct
- 4Potassium: high — Potassium 5.3 mmol/L (was 4.9)Lab 22 Oct
- 5Haemoglobin: low — Hemoglobin 11.6 g/dL (was 12.1)Lab 22 Oct
- 6Vitamin D: insufficient — Vitamin D (25-Hydroxy) 22 ng/mLLab 22 Oct
Blood pressure
Home avg 126/76 (n=4)Clinic 128/78, P 62Target <130/80 Systolic Diastolic
Cardiometabolic labs · current vs previous
| Test | Current | Previous | Δ | Ref / target |
|---|---|---|---|---|
| Cholesterol – LDL | 68 Oct 26 | 74 Apr 26 | ▼ | <70 mg/dL |
| Non-HDL Cholesterol | 92 Oct 26 | 99 Apr 26 | ▼ | <100 mg/dL |
| Cholesterol – HDL | 52 Oct 26 | 51 Apr 26 | ▬ | 50> mg/dL |
| Triglycerides | 120 Oct 26 | 125 Apr 26 | ▼ | <150 mg/dL |
| HbA1c | 5.8 Oct 26 | 5.7 Apr 26 | ▬ | Normal % |
| Fasting Blood Sugar | 101 Oct 26 | 99 Apr 26 | ▬ | Low mg/dL |
| eGFR | 58 Oct 26 | 63 Apr 26 | ▼ | Severely reduced mL/min/1.73m² |
| Serum Creatinine | 1.05 Oct 26 | 0.98 Apr 26 | ▲ | 0.6–1.1 mg/dL |
| Potassium | 5.3 Oct 26 | 4.9 Apr 26 | ▲ | 3.5–5.1 mmol/L |
| Sodium | 136 Oct 26 | 137 Apr 26 | ▬ | 136–145 mmol/L |
| Uric Acid, Serum | 4.6 Oct 26 | — | 2.6–6 mg/dL | |
| TSH Ultrasensitive | 6.8 Oct 26 | 4.9 Apr 26 | ▲ | 0.27–4.2 µIU/mL |
| Hemoglobin | 11.6 Oct 26 | 12.1 Apr 26 | ▼ | 12–15.5 g/dL |
| SGPT (Alanine Transaminase) | 20 Oct 26 | — | <33 U/L | |
| Vitamin D (25-Hydroxy) | 22 Oct 26 | — | Deficient ng/mL |
Hover a row for what the test means. Full panel in the family view → All reports.
Review & approve
Approved by Dr. Kajal Nanda. Visible to family and referring doctor.
Medications
- Aspirin 75 mg After lunch · since 2023Adherent
- Atorvastatin 40 mg Night · since 2023Adherent
- Metoprolol 25 mg Morning and night · since 2023Adherent
- Ramipril 5 mg Morning · since 2023Can raise potassium; kidneys monitoredAdherent
Risk profile
Previous heart attackKidney function reducedMild anaemiaWalks dailyNever smokedBMI 25.7 · waist 86 cm
CV risk score: tool to be chosen by Dr. Kajal
History & previous tests
- Heart attack, treated with a stent since 2023 · Stent in LAD artery, Mar 2023
- High blood pressure since 2014 · Well controlled
- Kidney function mildly reduced since 2026 · New finding
- Angioplasty (stent) (9 Mar 2023): Single stent to LAD
- Echo (20 Feb 2026): Ejection fraction 50%; mild wall-motion change
- ECG (24 Oct 2026): Sinus rhythm; old changes, no new ones
Assessment & plan sample text
Impression: CAD post-PCI (2023), hypertension controlled, LDL at goal. New eGFR decline with mild hyperkalaemia (K 5.3) on ACE inhibitor. Subclinical hypothyroidism. Mild microcytic anaemia.
- Repeat RFT + electrolytes in 2 weeks
- Liaise with treating cardiologist re ACE inhibitor
- Iron studies; review aspirin-related blood loss
- Repeat TSH
Investigations: RFT + electrolytes, Iron studies, ferritin, TSH, free T4, Urine ACR
Referral: Treating cardiologist informed
Next review: 12 Nov 2026