Chart · view recorded under the Health care operations purpose
✦ AI Ask about this patient
✦ AI Start ambient note
✦ AI Draft instructions
Drafts awaiting signature
0
AI summary
drafted by claude-sonnet-5 from this record · verify against the chart
Jose Begay is a 58-year-old male with chronic obstructive pulmonary disease, chronic kidney disease stage 2, and allergic rhinitis, managed with tiotropium and loratadine. He was seen most recently at urgent care for an allergic rhinitis flare, with prior visits for routine and health maintenance care.
Drives care
- COPD on tiotropium
- CKD stage 2
- Allergic rhinitis on loratadine
Watch
- Low BMI (18.8 kg/m2) - assess for unintentional weight loss given COPD
- No recent CKD labs (e.g., creatinine/eGFR) documented to confirm stage
- No recent pulmonary function or COPD exacerbation assessment on file
Active problems
| Condition | Status | Onset |
|---|---|---|
| Chronic kidney disease stage 2 (disorder) | active | Jun 23, 2019 |
| Allergic rhinitis (disorder) | active | Jul 22, 2018 |
| Chronic obstructive pulmonary disease (disorder) | active | Sep 9, 2012 |
Active medications
| Medication | Dosage | Since |
|---|---|---|
| Tiotropium 18 mcg inhaler | daily | Feb 24, 2026 |
| Loratadine 10 MG Oral Tablet | daily | Jul 6, 2022 |
Allergies
| Substance | Reaction | Verification |
|---|---|---|
| No known allergies recorded. | ||
Recent results
| Test | Value | When |
|---|---|---|
| Hemoglobin | 15.7 g/dL | Aug 17, 2026 |
| Heart rate | 76.6 /min | Jan 7, 2026 |
| Hemoglobin A1c | 8.7 % | Dec 20, 2025 |
| Oxygen saturation | 97.8 % | Oct 19, 2025 |
| Body mass index abnormal | 18.8 kg/m2 | Sep 22, 2025 |
| Diastolic blood pressure | 63.5 mmHg | Apr 29, 2025 |
| Body mass index | 30.6 kg/m2 | Apr 28, 2025 |
| Systolic blood pressure | 119.4 mmHg | Jan 6, 2025 |
| Total cholesterol | 149.7 mg/dL | Dec 24, 2024 |
| Systolic blood pressure | 120.7 mmHg | Aug 22, 2024 |
| Systolic blood pressure | 142 mmHg | May 5, 2024 |
| Systolic blood pressure | 135.6 mmHg | Apr 15, 2024 |
| Glucose | 128.7 mg/dL | Oct 27, 2023 |
| Total cholesterol | 189 mg/dL | Jul 28, 2023 |
| Heart rate | 62 /min | Jun 13, 2023 |
| Heart rate | 57.1 /min | May 27, 2023 |
| Oxygen saturation | 92.9 % | May 9, 2023 |
| Total cholesterol | 212.5 mg/dL | Mar 18, 2023 |
| Heart rate | 82.1 /min | Sep 13, 2022 |
Notes & documents
| Document | Author | Date | |
|---|---|---|---|
| Progress note | Dr. Hana Suzuki | Jun 11, 2023 | Read |
Claims
| Claim | Payer | Date | Status | Billed | Paid | |
|---|---|---|---|---|---|---|
| CLM-G0100170 | UnitedHealthcare | Dec 25, 2024 | denied | $120.75 | $0.00 | Lines |
| CLM-G0100169 | UnitedHealthcare | Dec 4, 2023 | paid | $606.79 | $376.44 | Lines |
Documentation drafts — this patient
No drafts for this patient yet. Ambient notes and AI-drafted documents land here, on the chart they belong to — and in the cross-patient Signature queue.