Substernal chest pain radiating to the left arm with dyspnea on exertion × 3 days. Denies syncope, no fevers.
43 y/o female with PMH of Type 2 Diabetes Mellitus (E11.9), CKD Stage 3a (N18.31) and essential hypertension, presenting after symptom onset on 03/12/2025. Compliant with metformin 1000 mg BID and lisinopril 20 mg daily. Last A1c 8.4% on 01/22/2025.
Longstanding type 2 diabetes mellitus with diabetic CKD stage 3a, essential hypertension, hyperlipidemia, and osteoarthritis of bilateral knees.
Penicillin — urticaria, high severity, onset 2014. No known food or latex allergies.
Metformin 1000 mg BID, lisinopril 20 mg daily, atorvastatin 40 mg QHS, aspirin 81 mg daily.
HbA1c 8.4% (01/22/2025) high · eGFR 45 mL/min low · LDL 142 mg/dL · Creatinine 1.6 mg/dL · Potassium 4.8 mmol/L.
Influenza (CVX 140) administered 10/12/2024. Tdap current (2022), pneumococcal PCV20 up to date.
Arthroscopy, right knee (CPT 27447) performed 09/10/2025; well healed, no effusion.
Optimize glycemic control, nephrology referral for CKD, repeat A1c and BMP in 3 months. Continue ACE inhibitor and statin; cardiology follow-up in 2 weeks for heart failure management.