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Elena Pilar Gomez is a 75-year-old woman with established ischemic heart disease status post coronary artery bypass grafting, managed with antiplatelet, beta-blocker, statin, and nitrate therapy. She also has metabolic syndrome, hypertension, osteoporosis, and a history of colon/rectal polyps under surveillance. Recent encounters note recurrent visits for dependent drug abuse, indicating an active substance use concern alongside her chronic conditions.
Drives care
- Ischemic heart disease with prior CABG
- Hypertension and metabolic syndrome
- Recurrent rectal and colon polyps
- Dependent drug abuse (recent recurrent encounters)
Watch
- Repeated recent encounters for dependent drug abuse - assess substance use status and support needs
- No recent lab/imaging results on file - confirm surveillance for cardiac status and polyp recurrence
- Chronic pain and migraine history - review for medication interactions given cardiac and bone regimens
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1 × Reproductive health · 8 × SUD — 42 CFR Part 2.
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them takes the dedicated role and path, and every access is audited as a disclosure.
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Active problems
| Condition | Status | Onset |
|---|---|---|
| Recurrent rectal polyp (disorder) | active | Nov 7, 2021 |
| Osteoporosis (disorder) | active | Dec 11, 2020 |
| Polyp of colon (disorder) | active | Aug 24, 2020 |
| Essential hypertension (disorder) | active | Oct 15, 2010 |
| Metabolic syndrome X (disorder) | active | Oct 15, 2010 |
| History of coronary artery bypass grafting (situation) | active | Sep 25, 1998 |
| Abnormal findings diagnostic imaging heart+coronary circulat (finding) | active | Sep 20, 1998 |
| Ischemic heart disease (disorder) | active | Sep 11, 1998 |
| Impacted molars (disorder) | active | Aug 25, 1990 |
| Chronic intractable migraine without aura (disorder) | active | Feb 12, 1990 |
| Chronic pain (finding) | active | Dec 7, 1989 |
| Anemia (disorder) | active | Nov 6, 1987 |
| Body mass index 30+ - obesity (finding) | active | Nov 6, 1987 |
| History of tubal ligation (situation) | active | Mar 28, 1986 |
| Recurrent urinary tract infection (disorder) | active | Jan 7, 1985 |
| Prediabetes (finding) | active | Oct 30, 1981 |
| Risk activity involvement (finding) | active | Oct 6, 1967 |
Active medications
| Medication | Dosage | Since |
|---|---|---|
| Alendronic acid 10 MG Oral Tablet | — | Jan 9, 2026 |
| Hydrochlorothiazide 25 MG Oral Tablet | — | Jan 9, 2026 |
| 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet | — | Sep 18, 1998 |
| Clopidogrel 75 MG Oral Tablet | — | Sep 18, 1998 |
| Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray | — | Sep 18, 1998 |
| Simvastatin 20 MG Oral Tablet | — | Sep 18, 1998 |
Allergies
| Substance | Reaction | Verification |
|---|---|---|
| No known allergies recorded. | ||
Recent results
| Test | Value | When |
|---|---|---|
| Potassium | 4.51 mmol/L | Jan 9, 2026 |
| Sodium | 143.41 mmol/L | Jan 9, 2026 |
| Glucose | 67.27 mg/dL | Jan 9, 2026 |
| Respiratory rate | 14 /min | Jan 9, 2026 |
| Heart rate | 79 /min | Jan 9, 2026 |
| BMI | 29.56 kg/m2 | Jan 9, 2026 |
| Body weight | 74.3 kg | Jan 9, 2026 |
| Pain severity | 3 {score} | Jan 9, 2026 |
| Body height | 158.5 cm | Jan 9, 2026 |
| Hemoglobin A1c | 5.8 % | Jan 9, 2026 |
| Pain severity | 8 {score} | Jan 10, 2025 |
| HDL cholesterol | 28.49 mg/dL | Jan 3, 2025 |
| LDL cholesterol | 104.07 mg/dL | Jan 3, 2025 |
| Triglycerides | 146.47 mg/dL | Jan 3, 2025 |
| Total cholesterol | 161.85 mg/dL | Jan 3, 2025 |
| Potassium | 4.66 mmol/L | Jan 3, 2025 |
| Sodium | 136.86 mmol/L | Jan 3, 2025 |
| Glucose | 96.27 mg/dL | Jan 3, 2025 |
| Respiratory rate | 13 /min | Jan 3, 2025 |
| Heart rate | 98 /min | Jan 3, 2025 |
| BMI | 29 kg/m2 | Jan 3, 2025 |
| Body weight | 72.9 kg | Jan 3, 2025 |
| Pain severity | 1 {score} | Jan 3, 2025 |
| Body height | 158.5 cm | Jan 3, 2025 |
| Hemoglobin A1c | 6.33 % | Jan 3, 2025 |
| Potassium | 3.8 mmol/L | Dec 29, 2023 |
| Sodium | 140.75 mmol/L | Dec 29, 2023 |
| Glucose | 94.67 mg/dL | Dec 29, 2023 |
| Respiratory rate | 15 /min | Dec 29, 2023 |
| Heart rate | 98 /min | Dec 29, 2023 |
Notes & documents
| Document | Author | Date | |
|---|---|---|---|
| No unrestricted documents. | |||
Claims
| Claim | Payer | Date | Status | Billed | Paid | |
|---|---|---|---|---|---|---|
| CLM-2026206000 | UnitedHealthcare | Jan 31, 2026 | paid | $516.95 | $345.12 | Lines |
| CLM-2026206001 | UnitedHealthcare | Jan 23, 2026 | paid | $87.21 | $1.33 | Lines |
| CLM-2026206004 | UnitedHealthcare | Jan 9, 2026 | paid | $785.58 | $2,423.62 | Lines |
| CLM-2026206003 | UnitedHealthcare | Jan 9, 2026 | paid | $32.49 | $0.00 | Lines |
| CLM-2026206002 | UnitedHealthcare | Jan 9, 2026 | denied | $35.62 | $0.00 | Lines |
| CLM-2026206005 | UnitedHealthcare | Jan 1, 2026 | pending | $516.95 | $0.00 | Lines |
| CLM-2026206006 | UnitedHealthcare | Dec 2, 2025 | paid | $516.95 | $345.12 | Lines |
| CLM-2026206007 | UnitedHealthcare | Nov 2, 2025 | paid | $516.95 | $345.12 | Lines |
Documentation drafts — this patient
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Imaging
| Study | Modality | Date | Series / images | |
|---|---|---|---|---|
| CR | Sep 25, 1998 | 1 / 1 | Open viewer | |
| US | Sep 25, 1998 | 1 / 1 | Open viewer |