Saúde Plena/Appointment in progress
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Appointment in progress · 24min 12s
Heloísa Pacheco
34 years old·Female·Insurance SulAmérica·Follow-up·with Dra. Marina
01 · Chief complaint
Why they came, in the patient's own words
Follow-up to go over the results of the 24h blood-pressure monitoring ordered at the last appointment.
02 · History of present illness
How things evolved since the last appointment
Patient reports good adherence to the prescribed medication, with no side effects. Home readings mostly between 120-135 / 78-86 mmHg, with occasional morning peaks (up to 148/92). Keeps exercising 3x a week (light running). Denies shortness of breath, chest pain, palpitations or leg swelling in the period.
good adherenceblood pressure under controldenies cardiac symptomsexercises regularly
03 · Personal and family history
- High blood pressurediagnosed Feb/24, stage 1
- Family historymother hypertensive, father had a heart attack at 58
- Smokingquit 6 years ago · 4 pack-years
04 · Lifestyle
- Sleep · around 7h a night, regular
- Alcohol · 1-2 drinks on the weekend
- Exercise · 5km run, 3x a week
- Diet · low-carb since 2023, no episodes of decompensation
05 · Last appointment
May 15 · Dra. Marina
Ordered 24h blood-pressure monitoring + full lipid panel. Kept current medication. Return in 30 days.