Doctor view · 2-minute read
Suresh Menon 58 M
Mulund West, Mumbai · Referred by Dr. A. Rao (Family physician (fictional))
Allergy: Sulfonamide antibiotics (rash)Draft · not approved
Summary
58 M, HTN 6 y on amlodipine + telmisartan. Home BP above target for 3 months (morning avg 146/92). LDL rising on atorvastatin 10 mg with ~2 missed doses/week. New HbA1c 6.1%. Vitamin D 18. Father MI at 52.
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 146/92 vs target <130/80 on 2 BP drug(s)6 home readings
- 2Bad cholesterol: above target — Cholesterol – LDL 142 mg/dL (was 128)Lab 22 Oct
- 3Blood fats: high — Triglycerides 190 mg/dL (was 175)Lab 22 Oct
- 4Vitamin D: deficient — Vitamin D (25-Hydroxy) 18 ng/mLLab 22 Oct
- 53-month sugar average: prediabetes range — HbA1c 6.1 % (was 5.9)Lab 22 Oct
- 6Missed doses — Atorvastatin: About 2 missed doses a weekPatient-reported
Blood pressure
Home avg 146/92 (n=6)Clinic 148/94, P 78Target <130/80 Systolic Diastolic
Cardiometabolic labs · current vs previous
| Test | Current | Previous | Δ | Ref / target |
|---|---|---|---|---|
| Cholesterol – LDL | 142 Oct 26 | 128 Apr 26 | ▲ | <100 mg/dL |
| Non-HDL Cholesterol | 180 Oct 26 | 163 Apr 26 | ▲ | <130 mg/dL |
| Cholesterol – HDL | 38 Oct 26 | 40 Apr 26 | ▼ | 40> mg/dL |
| Triglycerides | 190 Oct 26 | 175 Apr 26 | ▲ | <150 mg/dL |
| HbA1c | 6.1 Oct 26 | 5.9 Apr 26 | ▲ | Normal % |
| Fasting Blood Sugar | 108 Oct 26 | 102 Apr 26 | ▲ | Low mg/dL |
| eGFR | 87 Oct 26 | 89 Apr 26 | ▬ | Severely reduced mL/min/1.73m² |
| Serum Creatinine | 1 Oct 26 | 0.98 Apr 26 | ▬ | 0.7–1.3 mg/dL |
| Potassium | 4.6 Oct 26 | 4.4 Apr 26 | ▲ | 3.5–5.1 mmol/L |
| Sodium | 139 Oct 26 | 140 Apr 26 | ▬ | 136–145 mmol/L |
| Uric Acid, Serum | 6.8 Oct 26 | — | 3.5–7.2 mg/dL | |
| TSH Ultrasensitive | 2.1 Oct 26 | — | 0.27–4.2 µIU/mL | |
| Hemoglobin | 14.2 Oct 26 | 14 Apr 26 | ▬ | 13–17 g/dL |
| SGPT (Alanine Transaminase) | 38 Oct 26 | — | <41 U/L | |
| Vitamin D (25-Hydroxy) | 18 Oct 26 | — | Deficient ng/mL |
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Medications
- Amlodipine 5 mg Morning · since 2020Evening ankle swelling reportedAdherent
- Telmisartan 40 mg Morning · since 2023Adherent
- Atorvastatin 10 mg Night, after dinner · since 2024About 2 missed doses a weekMissed
Risk profile
Father: heart attack at 52PrediabetesWaist 98 cmSits most of the dayHigh-salt dietSleeps ~5.5 hQuit tobacco in 2019BMI 28 · waist 98 cm
CV risk score: tool to be chosen by Dr. Kajal
History & previous tests
- High blood pressure since 2020 · Above target on home readings
- High cholesterol since 2024
- Prediabetes since 2026 · New this year
- ECG (14 Mar 2025): Sinus rhythm; LVH voltage criteria
- Echo: Not done yet
Assessment & plan sample text
Impression: Essential hypertension, uncontrolled on home readings. Dyslipidaemia not at goal. Prediabetes. Vitamin D deficiency.
- [Doctor's decision on BP regimen]
- [Statin plan]
- Adherence support: evening reminder
- Lifestyle: salt < 5 g/day, walk 30 min × 5 days
Investigations: 2D echo, Urine albumin-creatinine ratio, Repeat lipids + HbA1c in 3 months
Referral: Cardiology if echo abnormal
Next review: 21 Nov 2026