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Mr. Tsosie is a 55-year-old male with a history of traumatic brain injury, longstanding type 2 diabetes with metabolic syndrome, hypertension, and obesity. He is on metformin and lisinopril for glycemic and blood pressure control. He has had routine preventive care including general exams, ophthalmic evaluation, and colon cancer screening.
Drives care
- Type 2 diabetes mellitus with metabolic syndrome (hyperglycemia, hypertriglyceridemia)
- Essential hypertension
- Obesity (BMI persistently ~30.1)
- History of traumatic brain injury and chronic sinusitis
Watch
- BMI unchanged at 30.1 kg/m2 across multiple visits over 2 years - weight management not improving
- No recent HbA1c or lipid panel results provided despite diabetes/hypertriglyceridemia diagnoses
- Anemia listed as active problem with no recent labs to confirm current status
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Active problems
| Condition | Status | Onset |
|---|---|---|
| Traumatic or nontraumatic brain injury (disorder) | active | Oct 28, 2020 |
| Chronic sinusitis (disorder) | active | May 16, 2020 |
| Essential hypertension (disorder) | active | Mar 18, 2020 |
| Hyperglycemia (disorder) | active | Jan 14, 2009 |
| Hypertriglyceridemia (disorder) | active | Jan 14, 2009 |
| Metabolic syndrome X (disorder) | active | Jan 14, 2009 |
| Diabetes mellitus type 2 (disorder) | active | Jan 9, 2008 |
| Anemia (disorder) | active | Jan 9, 2008 |
| Body mass index 30+ - obesity (finding) | active | Jan 9, 2008 |
Active medications
| Medication | Dosage | Since |
|---|---|---|
| 24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet | — | Apr 29, 2026 |
| lisinopril 10 MG Oral Tablet | — | Apr 29, 2026 |
Allergies
| Substance | Reaction | Verification |
|---|---|---|
| No known allergies recorded. | ||
Recent results
| Test | Value | When |
|---|---|---|
| eGFR | 157.74 mL/min/{1.73_m2} | Apr 29, 2026 |
| HDL cholesterol | 61.72 mg/dL | Apr 29, 2026 |
| LDL cholesterol | 141.99 mg/dL | Apr 29, 2026 |
| Triglycerides | 114.64 mg/dL | Apr 29, 2026 |
| Total cholesterol | 226.64 mg/dL | Apr 29, 2026 |
| Potassium | 5.19 mmol/L | Apr 29, 2026 |
| Sodium | 136.99 mmol/L | Apr 29, 2026 |
| Glucose | 73.51 mg/dL | Apr 29, 2026 |
| Respiratory rate | 15 /min | Apr 29, 2026 |
| Heart rate | 64 /min | Apr 29, 2026 |
| BMI abnormal | 30.12 kg/m2 | Apr 29, 2026 |
| Body weight | 82.7 kg | Apr 29, 2026 |
| Pain severity | 2 {score} | Apr 29, 2026 |
| Body height | 165.7 cm | Apr 29, 2026 |
| Hemoglobin A1c | 6.03 % | Apr 29, 2026 |
| eGFR | 152.52 mL/min/{1.73_m2} | Apr 23, 2025 |
| HDL cholesterol | 49.12 mg/dL | Apr 23, 2025 |
| LDL cholesterol | 99.03 mg/dL | Apr 23, 2025 |
| Triglycerides | 123.07 mg/dL | Apr 23, 2025 |
| Total cholesterol | 172.76 mg/dL | Apr 23, 2025 |
| Potassium | 5.03 mmol/L | Apr 23, 2025 |
| Sodium | 142.25 mmol/L | Apr 23, 2025 |
| Glucose | 99.23 mg/dL | Apr 23, 2025 |
| Respiratory rate | 14 /min | Apr 23, 2025 |
| Heart rate | 84 /min | Apr 23, 2025 |
| BMI abnormal | 30.12 kg/m2 | Apr 23, 2025 |
| Body weight | 82.7 kg | Apr 23, 2025 |
| Pain severity | 3 {score} | Apr 23, 2025 |
| Body height | 165.7 cm | Apr 23, 2025 |
| Hemoglobin A1c | 6.03 % | Apr 23, 2025 |
Notes & documents
| Document | Author | Date | |
|---|---|---|---|
| No unrestricted documents. | |||
Claims
| Claim | Payer | Date | Status | Billed | Paid | |
|---|---|---|---|---|---|---|
| CLM-2026245002 | Medicare | Apr 29, 2026 | paid | $1,444.70 | $1,046.32 | Lines |
| CLM-2026245001 | Medicare | Apr 29, 2026 | denied | $34.22 | $0.00 | Lines |
| CLM-2026245000 | Medicare | Apr 29, 2026 | paid | $38.27 | $0.00 | Lines |
| CLM-2026245004 | Medicare | Feb 6, 2026 | paid | $2,730.98 | $2,070.72 | Lines |
| CLM-2026245003 | Medicare | Feb 6, 2026 | paid | $129.94 | $0.00 | Lines |
| CLM-2026245005 | Medicare | Oct 21, 2025 | paid | $8,723.26 | $6,910.17 | Lines |
| CLM-2026245006 | Medicare | May 7, 2025 | paid | $87.37 | $1.46 | Lines |
| CLM-2026245007 | Medicare | Apr 23, 2025 | paid | $42.71 | $0.00 | Lines |
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Imaging
| Study | Modality | Date | Series / images | |
|---|---|---|---|---|
| DX | Oct 14, 2023 | 1 / 1 | Open viewer |