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Elena is a 61-year-old woman with chronic low back pain, knee osteoarthritis, obesity, and asthma managed with NSAIDs, acetaminophen, and an albuterol inhaler. She had a recent urgent care visit for asthma and has lab values suggesting possible undiagnosed or poorly controlled diabetes that isn't reflected in her problem list or medications.
Drives care
- Chronic low back pain
- Osteoarthritis of knee
- Obesity (BMI 30+)
- Asthma
Watch
- Hemoglobin A1c 9.5% (2023) suggests uncontrolled diabetes, not on problem list or treated
- Glucose 198.6 mg/dL (2024) elevated, correlate with A1c and consider diabetes workup
- Recent urgent care visit for asthma (2026-03-20) - assess control and need for escalation
Active problems
| Condition | Status | Onset |
|---|---|---|
| Chronic low back pain (finding) | active | Mar 24, 2023 |
| Body mass index 30+ - obesity (finding) | active | Dec 24, 2020 |
| Osteoarthritis of knee (disorder) | active | Dec 16, 2008 |
| Asthma (disorder) | active | Feb 9, 2008 |
Active medications
| Medication | Dosage | Since |
|---|---|---|
| Naproxen 500 MG Oral Tablet | twice daily as needed | Jun 24, 2026 |
| Acetaminophen 500 MG | as needed | Apr 26, 2024 |
| Albuterol 90 mcg inhaler | 2 puffs as needed | May 7, 2023 |
Allergies
| Substance | Reaction | Verification |
|---|---|---|
| No known allergies recorded. | ||
Recent results
| Test | Value | When |
|---|---|---|
| Glucose | 189.6 mg/dL | Jul 20, 2026 |
| Systolic blood pressure | 149.6 mmHg | Jun 28, 2026 |
| Glucose | 168.4 mg/dL | Mar 20, 2026 |
| Hemoglobin | 14.7 g/dL | Feb 13, 2026 |
| Oxygen saturation | 97.8 % | Jan 8, 2026 |
| Diastolic blood pressure abnormal | 59 mmHg | Nov 20, 2025 |
| Oxygen saturation | 94.5 % | Jul 21, 2025 |
| Diastolic blood pressure | 62.5 mmHg | May 28, 2025 |
| Glucose | 89 mg/dL | May 21, 2025 |
| Heart rate | 85.9 /min | Feb 17, 2025 |
| Glucose abnormal | 198.6 mg/dL | Dec 8, 2024 |
| Body mass index | 21.6 kg/m2 | Jul 23, 2024 |
| Body mass index | 33.4 kg/m2 | Jul 14, 2024 |
| Hemoglobin | 12.3 g/dL | Mar 9, 2024 |
| Hemoglobin A1c abnormal | 9.5 % | Aug 19, 2023 |
| Hemoglobin | 15.9 g/dL | Apr 18, 2023 |
| Systolic blood pressure | 122.8 mmHg | Dec 23, 2022 |
| TSH | 5.3 mIU/L | Oct 25, 2022 |
Notes & documents
| Document | Author | Date | |
|---|---|---|---|
| Progress note | Dr. Rafael Ortiz | Apr 27, 2024 | Read |
Claims
| Claim | Payer | Date | Status | Billed | Paid | |
|---|---|---|---|---|---|---|
| CLM-G0100183 | Blue Cross Blue Shield | Jul 19, 2025 | paid | $435.51 | $260.39 | Lines |
| CLM-G0100182 | Blue Cross Blue Shield | Aug 24, 2024 | paid | $131.91 | $76.53 | Lines |
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