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Joaquin Gomez is a 48-year-old male with Medicaid coverage and a history of hyperlipidemia diagnosed in 2018, currently managed with nightly rosuvastatin. Despite treatment, his lipid panels show persistently elevated cholesterol levels, and he also has findings suggestive of obesity, mild renal impairment, and possible thyroid dysfunction. His most recent visits have focused on routine health maintenance.
Drives care
- Hyperlipidemia, poorly controlled on statin therapy
- Elevated LDL and total cholesterol despite treatment
- Obesity (BMI 39.3)
- Possible subclinical hypothyroidism (elevated TSH)
Watch
- LDL remains high (178.2 mg/dL) despite statin use - consider therapy adjustment
- Creatinine 1.5 mg/dL - assess renal function
- TSH 7.2 mIU/L - recheck thyroid function to rule out hypothyroidism
Active problems
| Condition | Status | Onset |
|---|---|---|
| Hyperlipidemia (disorder) | active | May 11, 2018 |
Active medications
| Medication | Dosage | Since |
|---|---|---|
| Rosuvastatin 10 MG Oral Tablet | 10 mg nightly | Apr 20, 2026 |
Allergies
| Substance | Reaction | Verification |
|---|---|---|
| No known allergies recorded. | ||
Recent results
| Test | Value | When |
|---|---|---|
| Total cholesterol abnormal | 236.3 mg/dL | Jun 22, 2026 |
| Creatinine abnormal | 1.5 mg/dL | Aug 21, 2025 |
| Oxygen saturation | 96.9 % | Aug 15, 2025 |
| LDL cholesterol abnormal | 178.2 mg/dL | Jun 6, 2025 |
| Body mass index abnormal | 39.3 kg/m2 | Apr 6, 2025 |
| Glucose | 134.9 mg/dL | Feb 18, 2025 |
| LDL cholesterol | 80.5 mg/dL | Dec 20, 2024 |
| LDL cholesterol | 94.8 mg/dL | Mar 13, 2024 |
| LDL cholesterol abnormal | 175.2 mg/dL | Jul 22, 2023 |
| Glucose | 168.8 mg/dL | Apr 10, 2023 |
| TSH abnormal | 7.2 mIU/L | Mar 16, 2023 |
Notes & documents
| Document | Author | Date | |
|---|---|---|---|
| Progress note | Dr. Anh Vo | Feb 20, 2025 | Read |