Doctor view · 2-minute read
Rajiv Khanna 46 M
Andheri West, Mumbai · Referred by Dr. M. Shah (General physician (fictional))
Allergy: No known drug allergiesDraft · not approved
Summary
46 M, new HTN (Sep 2026) on amlodipine 5; home ~142/92. Smoker 10/day, BMI 31. TG 280, LDL 160, HDL 34, ALT 78/GGT 90 (fatty-liver pattern), HbA1c 6.3, uric acid 8.4, vit D 14.
AI-drafted from structured data → edited and approved by the doctor
Red flags & open actions
Rule thresholds pending Dr. Kajal- 1BP above target — Home avg 142/92 vs target <130/80 on 1 BP drug(s)4 home readings
- 2Bad cholesterol: above target — Cholesterol – LDL 160 mg/dL (was 145)Lab 22 Oct
- 3Liver enzyme ALT: high — SGPT (Alanine Transaminase) 78 U/L (was 55)Lab 22 Oct
- 4Blood fats: high — Triglycerides 280 mg/dL (was 230)Lab 22 Oct
- 5Uric acid: high — Uric Acid, Serum 8.4 mg/dL (was 7.6)Lab 22 Oct
- 6Vitamin D: deficient — Vitamin D (25-Hydroxy) 14 ng/mLLab 22 Oct
Blood pressure
Home avg 142/92 (n=4)Clinic 146/94, P 84Target <130/80 Systolic Diastolic
Cardiometabolic labs · current vs previous
| Test | Current | Previous | Δ | Ref / target |
|---|---|---|---|---|
| Cholesterol – LDL | 160 Oct 26 | 145 Nov 24 | ▲ | <100 mg/dL |
| Non-HDL Cholesterol | 216 Oct 26 | 192 Nov 24 | ▲ | <130 mg/dL |
| Cholesterol – HDL | 34 Oct 26 | 36 Nov 24 | ▼ | 40> mg/dL |
| Triglycerides | 280 Oct 26 | 230 Nov 24 | ▲ | <150 mg/dL |
| HbA1c | 6.3 Oct 26 | 5.9 Nov 24 | ▲ | Normal % |
| Fasting Blood Sugar | 118 Oct 26 | 104 Nov 24 | ▲ | Low mg/dL |
| eGFR | 84 Oct 26 | 90 Nov 24 | ▼ | Severely reduced mL/min/1.73m² |
| Serum Creatinine | 1.1 Oct 26 | 1.05 Nov 24 | ▲ | 0.7–1.3 mg/dL |
| Potassium | 4.3 Oct 26 | — | 3.5–5.1 mmol/L | |
| Sodium | 140 Oct 26 | — | 136–145 mmol/L | |
| Uric Acid, Serum | 8.4 Oct 26 | 7.6 Nov 24 | ▲ | 3.5–7.2 mg/dL |
| TSH Ultrasensitive | 2.1 Oct 26 | — | 0.27–4.2 µIU/mL | |
| Hemoglobin | 15.6 Oct 26 | — | 13–17 g/dL | |
| SGPT (Alanine Transaminase) | 78 Oct 26 | 55 Nov 24 | ▲ | <41 U/L |
| Vitamin D (25-Hydroxy) | 14 Oct 26 | — | Deficient ng/mL |
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Medications
- Amlodipine 5 mg Morning · since Sep 2026Adherent
Risk profile
Smokes ~10 a dayBMI 31Waist 104 cmPrediabetesHigh uric acidDesk job, long hoursMother: high BPBMI 31 · waist 104 cm
CV risk score: tool to be chosen by Dr. Kajal
History & previous tests
- High blood pressure since Sep 2026 · Newly diagnosed
- Fatty liver (on blood test) since 2026
- High cholesterol and triglycerides since 2024 · Not on treatment
- ECG (8 Sept 2026): Normal
- Ultrasound abdomen: Not done; suggested for fatty liver
Assessment & plan sample text
Impression: Stage 2 hypertension, newly diagnosed, improving. Mixed dyslipidaemia. Probable MASLD (fatty liver). Prediabetes. Hyperuricaemia. Current smoker.
- Smoking cessation (counselling ± pharmacotherapy)
- [Doctor's decision on lipid therapy]
- Structured weight-loss target 5–7%
- Vitamin D replacement
Investigations: USG abdomen, Repeat lipids, HbA1c, LFT in 3 months
Next review: 14 Nov 2026