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Clinical summary

Synthesised from the patient's history

Juan Pérez García, 58 years, male.

Recorded in the chart: hypertension (since 2018), dyslipidemia (LDL 178 mg/dL at diagnosis), type 2 diabetes (HbA1c 7.2 % at the latest labs) and active smoking (15 cig/day, 35 pack-years). Family history on file: father deceased from MI at age 62.

Prescribed medication: enalapril 20 mg/24 h, atorvastatin 40 mg/24 h and metformin 850 mg/12 h. Allergy on file: penicillin.

Latest labs (Oct 2024): glucose 158 mg/dL, HbA1c 7.2 %, LDL 142 mg/dL, troponins negative. Prior ECG: incomplete right bundle branch block.

Generated from the patient's history

Relevant for your specialty

Cardiology
2 records linked to Cardiology
Family history of ischemic heart disease
Recorded in the anamnesis: father deceased from MI at age 62.
Cardiovascular data on file
Hypertension under treatment, dyslipidemia with LDL 142 mg/dL at the latest labs, T2DM with HbA1c 7.2 % and active smoking (15 cig/day, 35 pack-years).
Filtered by active specialty

Records worth having in mind

5 entries highlighted from the patient's chart
Allergy
Documented penicillin allergy
Recorded as an adverse reaction in the patient's chart.
Labs
LDL 142 mg/dL at latest labs
Result recorded in the Oct 2024 panel. Prior value at diagnosis: 178 mg/dL.
Labs
HbA1c 7.2 % at latest labs
Figure recorded in the Oct 2024 panel. Prescribed medication: metformin 850 mg/12 h.
Lifestyle
Active smoking on file
Chart: 15 cig/day · 35 pack-years.
Prior ECG
Prior ECG: incomplete right bundle branch block
Finding recorded in an earlier ECG on file. No current trace available to compare.
Entries grouped by record type

Structured consultation draft

Transcribed and organised from the recording
Chief complaint (as reported by the patient)

3-day chest pain, described as retrosternal pressure radiating to the left arm. Reported mostly with exertion. Patient did not mention dyspnea at rest.

History mentioned in the conversation

The patient reports taking medication for high blood pressure and cholesterol for years. Matches the entries on file.

Plan / assessment

To be completed by the clinician. SofIA does not propose diagnoses or treatments.

Suggested ICD-10 codes (administrative)
R07.9 · Chest pain I10 · Essential HTN E78.5 · Dyslipidemia E11.9 · T2DM, no complication
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