Rosa Elvira Martinez
“Me agarra una presión en el pecho cuando camino rápido.”Review the chart below, then begin the encounter. The patient will share some information on her own and hold back the rest; your job is to ask.
Begin consultation →Nurse intake
54F with hypertension and hyperlipidemia presents for 3 weeks of intermittent chest pressure. Symptoms occur when walking uphill or carrying groceries, improve with rest, and last 5-10 minutes. No active chest pain at intake. She reports mild shortness of breath with episodes and has been using antacids without clear benefit.
Problem list
- Hypertension
- Hyperlipidemia
- GERD
- Prediabetes
Active medications
- Amlodipine5 mg · once daily
- Atorvastatin20 mg · once daily at bedtime
- Omeprazole20 mg · once daily as needed
6 months ago
- Total cholesterol232 mg/dLHRef <200
- LDL148 mg/dLHRef <100
- HDL46 mg/dLLRef >50
- Triglycerides190 mg/dLHRef <150
- HbA1c6.1%HRef <5.7%
- Creatinine0.8 mg/dLRef 0.5-1.1
- eGFR92 mL/min/1.73m²Ref >60
| Test | Value | Reference |
|---|---|---|
| Total cholesterol | 232 mg/dLH | <200 |
| LDL | 148 mg/dLH | <100 |
| HDL | 46 mg/dLL | >50 |
| Triglycerides | 190 mg/dLH | <150 |
| HbA1c | 6.1%H | <5.7% |
| Creatinine | 0.8 mg/dL | 0.5-1.1 |
| eGFR | 92 mL/min/1.73m² | >60 |
History
Lives in Chelsea with her husband and teenage son. Works cleaning offices in the evening. Former smoker, quit 6 years ago; 12 pack-year history. No alcohol or drug use. Came from San Miguel 18 years ago.
History
Father died suddenly at 59, family was told it was "del corazón." Mother has hypertension and diabetes.
ECG · today at intake
Normal sinus rhythm. No ST elevations. Nonspecific T-wave flattening in lateral leads.