The artifacts · 20 of 20 types

Patient snapshot

Who this patient is, in one screen: diagnoses, current therapy, values that matter, what is open.

Open alone
Patient snapshot

Anna Keller, 47

Anna Keller, 47 · 16 September 2026 · Signed, in the chart

Diagnoses
Arterial hypertension since September 2023. Prediabetes, HbA1c 5.9 % in May 2026. Mild hepatic steatosis on ultrasound. Generalised anxiety since 2025.
Current therapy
Ramipril 5 mg in the morning, sertraline 50 mg. Simvastatin 20 mg stopped in March 2024 for muscle aches with a CK of 210 U/l; no lipid-lowering therapy since.
Values that matter
LDL 162 mg/dl, non-HDL 186 mg/dl, home blood pressure 136/86 mmHg, BMI 27.4, eGFR 92 ml/min. SCORE2 about 3 %.
Family history
Father: myocardial infarction at 58. Mother: type 2 diabetes and hypertension.

Open

  • Lipoprotein(a) never measuredDiscussed in May, not ordered.
  • HbA1c 5.6 → 5.9 % across three reportsAbove the threshold for the first time in May. No control ordered since.
  • FIB-4 never calculatedAge, AST, ALT and platelets are all in the chart.
  • Tetanus-diphtheria booster, due since August 2025Last dose in August 2015.

Sources

Lab 08.05.2026Ultrasound 08.05.2026Visit 14.03.2024Intake 20.09.2023

Read from 14 documents in the chart, newest first. Every line points to the document it comes from.

Questionnaire

What the practice sent to the patient's phone, and what came back: the same sheet, before and after she filled it in.

Open alone
Questionnaire

Check-up questionnaire, sent 12 September

Anna Keller, 47 · 12 September 2026 · Shared with the patient, 12 September 2026, opened

As it reached her phone

What would you like to talk about?
Routine checkA new problemSomething from the last visitMedication
Your home blood pressure last weekNew

Mean 136/86, highest 148/92, mornings and evenings

The mean of the week, and the highest single reading. Both are in your plan of 16 March.

Weight84 kg
WaistOptional94 cm

Measured at the navel, standing, after breathing out. Together with the weight this is what the risk calculation uses.

Has anything about your medication changed since May?
Nothing has changedA dose changedSomething was stoppedSomething new was added
You stopped a cholesterol tablet in 2024. What happened then?New

Muscle aches in both thighs after six weeks. Gone two weeks after stopping.

Asked because the chart records simvastatin stopped in March 2024 without a reason.

How many days a week do you move for at least twenty minutes?
012345678910
Anything new since the last visit?OptionalNew

Headaches in the afternoon, two or three times a week

Answers are stored in the chart under your name and marked as entered by the patient. Nothing is shared with anyone else.

Sources

Practice template, 23 questionsChart of Anna Keller, 14 documentsPlan 16.03.2026

Written from the practice's own check-up template and the chart: questions the record already answers were dropped, questions the record raises were added. Sent as one link, no app to install, answers back in the chart.

Intake summary

What the patient answered before the visit, as questions and answers, new answers marked.

Open alone
Intake summary

Check-up, 16 September 2026

Anna Keller, 47 · 14 September 2026 · Signed, in the chart

What she answered

Home blood pressure, last week
Mean 136/86 mmHg, highest 148/92, measured mornings and evenings — new
Weight and waist
84 kg, waist 94 cm; 3 kg more than in May
Medication changes since May
None. Ramipril 5 mg every morning, no missed days
The statin you stopped in 2024
Muscle aches in both thighs after six weeks on simvastatin; gone two weeks after stopping — new
Family history
Father: heart attack at 58. Mother: type 2 diabetes at 61
Movement
Walks 20 minutes on 2 to 3 days; no other exercise
Anything since the last visit
Headaches in the afternoon, two or three times a week — new
What you want to talk about
Whether I need the cholesterol tablet again

The sheet as she filled it in

What would you like to talk about?
Routine checkA new problemSomething from the last visitMedication
Your home blood pressure last weekNew

Mean 136/86, highest 148/92, mornings and evenings

The mean of the week, and the highest single reading. Both are in your plan of 16 March.

Weight84 kg
WaistOptional94 cm

Measured at the navel, standing, after breathing out. Together with the weight this is what the risk calculation uses.

Has anything about your medication changed since May?
Nothing has changedA dose changedSomething was stoppedSomething new was added
You stopped a cholesterol tablet in 2024. What happened then?New

Muscle aches in both thighs after six weeks. Gone two weeks after stopping.

Asked because the chart records simvastatin stopped in March 2024 without a reason.

How many days a week do you move for at least twenty minutes?
012345678910
Anything new since the last visit?OptionalNew

Headaches in the afternoon, two or three times a week

Answered by the patient on her phone, 14 September 2026. Stored in the chart, dated, marked as answered by the patient.

Lab order

The panel read from the intake and the chart, grouped by what each marker decides, with what the insurer covers and what the patient pays; sent to the laboratory as an order.

Open alone
Lab order

Prevention panel, 34 markers

Markus Vogel, 44 · 11 September 2026 · Signed, in the chart

The order

GroupMarkersWhyBilling
Heart and lipidsTotal, LDL, HDL, non-HDL cholesterol, triglyceridesSCORE2 input, ESC/EAS goalsCovered, check-up
Apolipoprotein B, lipoprotein(a)ESC/EAS goal; Lp(a) once in a lifetime (EAS 2022)Private
SugarFasting glucoseADA criteriaCovered, check-up
HbA1c, fasting insulin, uric acidADA criteria; HOMA-IR; father with type 2 diabetesPrivate
LiverALT, AST, GGT, alkaline phosphatase, bilirubin, albuminFIB-4 (EASL 2024); ALT 39 in 2019; alcohol in the intakePrivate
KidneyCreatinine with eGFR, urine albumin/creatinineKDIGO stagingPrivate; urine strip covered
ThyroidTSH, free T4Tiredness in the intakePrivate
Iron and vitaminsFerritin, transferrin saturation, 25-OH vitamin D, B12, folateTiredness; deficiency commonPrivate
Inflammationhs-CRPRisk modifier (AHA/CDC)Private
Blood countHaemoglobin, leukocytes, platelets, MCVPlatelets for FIB-4Private

Grouped by what each marker decides. Covered means billed to the statutory insurer through the check-up; the rest goes on the private form.

Not ordered, and why

  • Testosterone, cortisol, omega-3 index, zinc, magnesiumOn the commercial panels he mentioned; no guideline asks for them in a 44-year-old without symptoms, and none changes a decision here.
  • PSANot recommended at 44 without a family history.
  • “Biological age”Not a laboratory value.

How it reaches the laboratory

Order
Sent through the laboratory's order-entry portal from the practice software; labels and the private form print with it. Where a practice has no order entry, the same sheet prints as the order.
Material
Serum, EDTA, NaF blood, spot urine. Fasting from 22:00 the evening before; water is fine.
Result
Returns as an LDT report into the chart, usually within two working days. Mosaic reads it the moment it lands and drafts the review.

Sources

ESC/EAS 2019EAS 2022 Lp(a)ADA 2026EASL 2024G-BA check-upKBV LDT 3

Drafted from the intake of 10 September and the 2019 report. Signed by Dr. med. Sarah Weber on 11 September and sent to the laboratory; the private form was signed by the patient in his app the same day.

Patient timeline

Years of letters, reports and notes on one line, every point cited to its document.

Open alone
Patient timeline

Three years in one line

Anna Keller, 47 · 16 September 2026 · Signed, in the chart

  • Sep 2023

    Hypertension diagnosed

    Ramipril 5 mg started. Family history recorded: father, myocardial infarction at 58.

    Visit 20.09.2023
  • Mar 2024

    Simvastatin stopped

    Muscle aches in both thighs after six weeks; resolved within two weeks.

    Visit 14.03.2024
  • May 2026

    Check-up

    LDL 162, HbA1c 5.9 %, ALT 41, vitamin D 21. Ultrasound: mild steatosis. SCORE2 calculated.

    Lab 08.05.2026
  • Sep 2026

    Home blood pressure

    Mean 136/86 mmHg over seven days, above the target of 130/80.

    Entered by the patient
  • Open

    Never measured

    Lipoprotein(a), once, given the family history.

    Guideline: ESC 2021

Built from visit notes, the laboratory reports and the ultrasound in the chart, plus what the patient entered herself.

Lab review

Every value against its range and against the earlier reports, with one sentence on what it means.

Open alone
Lab review

Laboratory report, 8 May 2026

Anna Keller, 47 · 8 May 2026 · Shared with the patient, 12 May 2026, opened

Cholesterol

4 values · 2 to look at
LDL cholesterol162mg/dl
Above rangeaim below 100rising

Rising over three reports; with her father's heart attack at 58 the target is below 100.

Non-HDL cholesterol186mg/dl
Above rangeaim below 130rising

Moves with LDL; the same target applies.

HDL cholesterol52mg/dl
In rangeabove 45
Triglycerides148mg/dl
In rangebelow 150

Blood sugar

2 values · 2 to look at
HbA1c5.9%
Above rangebelow 5.7rising

First time above the threshold: prediabetes. Weight and movement first, control in three months.

Fasting glucose104mg/dl
Above rangebelow 100rising

Fits the HbA1c.

Liver

3 values · 2 to look at
ALT (GPT)41U/l
Above rangebelow 35rising

Mild; fits the steatosis on ultrasound. No barrier to a statin.

AST (GOT)28U/l
In rangebelow 35
GGT44U/l
Above rangebelow 40

Mildly raised. Same picture as ALT.

Kidney

2 values
Creatinine0.78mg/dl
In range0.5 to 0.9
eGFR92ml/min
In rangeabove 90

Other

4 values · 1 to look at
Vitamin D21ng/ml
Below range30 to 50falling

Low; 1,000 IU daily.

TSH1.8mU/l
In range0.4 to 4.0
Ferritin48ng/ml
In range15 to 150
CK96U/l
In rangebelow 170

What follows from this

  • Atorvastatin 20 mg in the eveningLDL, ALT and CK again after eight weeks
  • Lipoprotein(a), onceNever measured; changes the risk estimate with the family history
  • HbA1c again in NovemberLifestyle first at 5.9 %, no metformin

Sources

Lab report 08.05.2026Ultrasound 08.05.2026ESC 2021

Read from the laboratory report of 8 May 2026 and compared with the reports of September 2023 and March 2024. Reference ranges from the laboratory, targets from the ESC prevention guideline.

Open findings

What the chart already shows more than once, and what follows from it that never happened.

Open alone
Open findings

Open in this chart

Anna Keller, 47 · 16 September 2026 · Signed, in the chart

Never measured

  • Lipoprotein(a), once in a lifetimeLDL 162 with a father who had a myocardial infarction at 58. The ESC prevention guideline lists it as a risk modifier; the chart holds no result.

Documented twice, no step taken

  • HbA1c 5.6 → 5.9 % across three reportsAbove the threshold for the first time in May. No control ordered since.
  • ALT and GGT raised alongside hepatic steatosis on ultrasoundAge, AST, ALT and platelets are all in the chart. FIB-4 was never calculated.

Recommended and not done

  • Tetanus-diphtheria booster, due since August 2025Noted at the check-up of May 2026, no appointment in the chart.

Sources

Lab 08.05.2026Ultrasound 08.05.2026Visit 14.03.2024ESC 2021

Assembled from 14 documents in the chart. Every line names the documents it rests on. Mosaic states which criterion is met; whether it applies to this patient is the physician's call.

Evidence answer

The answer to a clinical question, with the studies and the guidelines it rests on.

Open alone
Evidence answer

A second statin after muscle aches on the first

Anna Keller, 47 · 16 September 2026 · Signed, in the chart

The evidence

The Cholesterol Treatment Trialists' meta-analysis of 27 trials found that each 1 mmol/l (39 mg/dl) reduction in LDL cholesterol lowered major vascular events by about a fifth. The proportional benefit was at least as large in people whose five-year risk was below 10 %.

The same collaboration pooled 19 double-blind trials for muscle symptoms. Muscle pain or weakness was reported by 27.1 % on a statin and 26.6 % on placebo; more than 90 % of the reports in the statin groups were not caused by the statin.

In SAMSON, 60 people who had stopped a statin for side effects took a statin, a placebo and no tablet in random months. The placebo months produced 90 % of the symptom burden of the statin months, and half of the participants were back on a statin six months later.

What this means for her

  • A different statin, at a moderate dose, in the eveningAfter symptoms of this kind the EAS consensus advises a rechallenge rather than permanent avoidance.
  • Her CK before the start is in the chart: 96 U/l in MayNew aches can be measured against her own baseline.
  • If a second statin also fails, the options without a statin come nextEzetimibe, then bempedoic acid. Both stand in the therapy options with their evidence.

Sources

Lancet 2012, CTTLancet 2022, CTT muscle symptomsN Engl J Med 2020, SAMSONEur Heart J 2015, EAS consensus

Written from two meta-analyses, one blinded trial and one consensus statement, read against this chart. Every number links to the publication it comes from.

Guideline comparison

The society's sentence, then the options for this patient: what applies, with a caveat, or is ruled out.

Open alone
Guideline comparison

ESC, applied to her

Anna Keller, 47 · 16 September 2026 · Signed, in the chart

For patients at high cardiovascular risk the ESC recommends an LDL target below 100 mg/dl and a blood pressure target of 120 to 129 mmHg systolic where tolerated.

ESC Guidelines on cardiovascular disease prevention, Eur Heart J 2021; ESC hypertension guideline 2024
AppliesStart a statin, low dose, different moleculeLDL 162 with a premature family history; atorvastatin 20 mg, CK and ALT after six weeks, given the myalgia on simvastatin
AppliesRamipril to 10 mgHome mean 136/86, above target; one step up before adding a second drug
CaveatLipoprotein(a), onceNever measured; changes the risk estimate with the family history
Ruled outMetforminHbA1c 5.9 %: prediabetes, lifestyle first, control in three months

The society's sentence is quoted, not paraphrased. What follows is this chart checked against it, value by value.

Therapy options

The options that apply, ranked, each with the guideline, the study behind it, the benefit in numbers and what this patient's own record says against it.

Open alone
Therapy options

Lowering her LDL, the options in order

Anna Keller, 47 · 16 September 2026 · Signed, in the chart

In order, with the evidence under each

1Atorvastatin 20 mg in the eveningAppliesApproved for this use

A different statin from the simvastatin she stopped, at a moderate dose. Her aches of 2024 fit statin-associated muscle symptoms with a CK below four times the upper limit, the pattern in which the consensus advises a second attempt.

CTT meta-analysis, 27 randomised trials, 174,149 participantsversus placebo or a less intensive statin

Major vascular events per 1 mmol/l of LDL
RR 0.79 (0.77–0.81)
Muscle pain or weakness, statin versus placebo
27.1 % versus 26.6 %
Population studied
Adults with and without vascular disease. The analysis reports people with a five-year risk below 10 % separately.
Where she differs
The trials did not select people with earlier muscle symptoms. For that question, the blinded trials stand in the evidence answer.
Data maturity
Individual participant data with about five years of follow-up. The pooled analysis of muscle symptoms followed in 2022.
Guideline
ESC/EAS 2019: at moderate risk an LDL goal below 100 mg/dl, with a statin as the first step. EAS consensus 2015: after muscle symptoms, a rechallenge with a different statin. ESC/EAS 2019
Sources
CTT, Lancet 2012CTT muscle symptoms, Lancet 2022

If the aches come back, check the CK and pause the tablet. Do not raise the dose into the symptoms.

Before it could startCK before the start96 U/l on 8 May 2026Liver values before the startALT 41 U/l on 8 May 2026. It fits the steatosis and is no reason to wait.Her medication checkedRamipril and sertraline, no interaction
2Rosuvastatin 5 mgAppliesApproved for this use

The second statin if atorvastatin brings the aches back. It lowers LDL at a small dose, which keeps the dose low for a patient who has reacted once.

JUPITER, 17,802 randomised, rosuvastatin 20 mgversus placebo

Primary endpoint, hazard ratio (95 % CI)
0.56 (0.46–0.69)
LDL reduction
50 %
Population studied
Men and women without cardiovascular disease, with an LDL below 130 mg/dl and an hsCRP of 2 mg/l or more.
Where she differs
Her LDL is higher than the trial allowed, and the dose studied was four times the one proposed here.
Data maturity
Stopped early after a median of 1.9 years for benefit, which tends to overstate the size of an effect.
Guideline
ESC/EAS 2019: statins as the first step; the choice of statin and dose follows tolerance and the distance to the goal. ESC/EAS 2019
Sources
Ridker, NEJM 2008
3Ezetimibe, then bempedoic acidIf a second statin also failsApproved, bempedoic acid for people who cannot take a statin

Neither is a statin. Ezetimibe lowers the uptake of cholesterol from the gut. Bempedoic acid acts one step before the statins and is activated only in the liver, which is why it was studied in people who could not take a statin.

CLEAR Outcomes, 13,970 randomised, bempedoic acid 180 mgversus placebo

Major cardiovascular events, hazard ratio (95 % CI)
0.87 (0.79–0.96)
LDL reduction beyond placebo
21.1 percentage points
Gout
3.1 % versus 2.1 %
Gallstones
2.2 % versus 1.2 %
Population studied
People who could not take a statin, with cardiovascular disease or at high risk of it. About 30 % were in primary prevention.
Where she differs
Her risk is lower than that of the trial population, so the absolute benefit for her would be smaller.
Data maturity
Event-driven, median follow-up 40.6 months.
Guideline
ESC/EAS 2019: ezetimibe if the goal is not reached on the tolerated statin dose, or alone if no statin is tolerated. ESC/EAS 2019
Sources
Nissen, NEJM 2023

Bempedoic acid raises uric acid. One value before the start is worth it in anyone with gout in the history.

Checked against everything she takes

Her medication list of 16 September, read against the product information of the option ranked first.

No actionAtorvastatin × ramiprilNo shared metabolic route.Continue both unchanged.
No actionAtorvastatin × sertralineNo clinically relevant interaction.Continue both unchanged.
WatchAtorvastatin × clarithromycinA strong CYP3A4 inhibitor. Not on her list today.If a macrolide is ever prescribed for an infection, pause atorvastatin for the course.

Read from her own record, not from the guideline

  • Simvastatin 20 mg, March 2024: muscle aches in both thighs, CK 210 U/lBelow four times the upper limit and gone within two weeks of stopping. That is what puts a second statin first.
  • LDL 162 mg/dl, father with a myocardial infarction at 58From 162 to below 100 mg/dl is a reduction of about 40 %, the range of a moderate statin dose. The blood test after eight weeks shows whether it closes the distance.
  • Lipoprotein(a) not yet measuredA high value would move her risk category, and with it the goal.

Sources

ESC/EAS 2019Lancet 2012, CTTN Engl J Med 2008, JUPITERN Engl J Med 2023, CLEAR OutcomesVisit 14.03.2024Lab 08.05.2026

Built from the studies behind each option and from this chart: the muscle aches of 2024, the LDL, the family history and the medication list. Where a study population differs from her, that sentence stands above the numbers. The order is a proposal with its reasons visible; the decision is the physician's.

Candidate list

The patients of the practice who could qualify, with what is met and what is still open.

Open alone
Candidate list

Criteria met, step not taken

Your practice · 16 September 2026 · Signed, in the chart

What the rules found

  • 9patientsTwo eGFR values between 30 and 59, more than 90 days apart, no chronic kidney disease in the chartThe criterion for stage 3 is two qualifying values, not one.Confirm the second value and the interval before coding
  • 6patientsThree or more antihypertensives and repeated hypokalaemia, no aldosterone-to-renin ratioGuidelines name this constellation as an indication to screen for primary aldosteronism.
  • 4patientsLDL above 190 mg/dl on two reports, no assessment for familial hypercholesterolaemiaThe Dutch Lipid Clinic Network score needs the LDL course, the medication, the age and the family history, all of which are in the chart.
  • 12patientsAge, AST, ALT and platelets all present, FIB-4 never calculatedThe score needs no new test.

What this list is not

  • It is not a diagnosisEvery line says which criterion the record meets, not what the patient has.
  • It is not a predictionNo model is guessing. The rules are the ones the guidelines state.
  • Nothing left the practiceThe charts were read where they are.

Every chart the practice has connected was checked against four documented criteria. A patient appears here only when the data behind the criterion is already in her record.

Treatment plan

Medications, tasks and appointments from the decision, dated, for your signature.

Open alone
Treatment plan

Plan after the check-up of 16 September

Anna Keller, 47 · 16 September 2026 · Shared with the patient, 16 September 2026, opened

Medication

  • Atorvastatin 20 mgOne tablet every evening · Lowers LDL cholesterolNew
  • Ramipril 10 mgOne tablet every morning · Blood pressureChanged
  • Sertraline 50 mgOne tablet every morning · Anxiety
  • Vitamin D3 1,000 IUOne tablet daily · Vitamin D was low in MayNew

What you do

  • Take atorvastatin every eveningWith or without food
  • Measure your blood pressure for seven days before 16 NovemberMorning and evening, seated, after five minutes of rest, two readings each time
  • Walk 30 minutes on five days a weekOr the equivalent in something you enjoy

When to call us

  • New or unusual muscle painNote when it started and where. Keep taking the tablet unless the pain is severe.

Appointments

  • Week of 9 Nov 2026Blood testLipids, liver, CK, potassium, kidney values, lipoprotein(a). No fasting needed.
  • 16 Nov 2026, 10:30Follow-up with Dr. WeberBring your blood pressure readings.
  • TodayTetanus-diphtheria boosterGiven in the practice. Next due in 2036.

Drafted from the visit of 16 September 2026 and the chart. Signed by Dr. med. Sarah Weber; every statement can be traced to the note.

Medication review

Everything the patient takes, what changed today, and what to watch.

Open alone
Medication review

Medication after the visit of 16 September

Anna Keller, 47 · 16 September 2026 · Shared with the patient, 16 September 2026, opened

  • Atorvastatin 20 mgOne tablet in the evening · Lowers LDL cholesterolNew
  • Ramipril 10 mgOne tablet in the morning · Blood pressure, increased from 5 mgChanged
  • Sertraline 50 mgOne tablet in the morning · Anxiety, unchanged since 2025
  • Vitamin D3 1,000 IUOne tablet daily · Vitamin D was low in MayNew

Stopped

  • Simvastatin 20 mg, stopped March 2024Muscle aches in both thighs after six weeks, CK 210 U/l. Resolved within two weeks.

What to watch

  • Potassium and kidney values two weeks after the ramipril increase
  • CK and ALT eight weeks after starting atorvastatin

Built from the medication list in the practice software and today's changes. Bring it to every visit, to other doctors and to the pharmacy.

Take-home

What the patient takes home: why, what to do, what to watch for, in plain language.

Open alone
Take-home

Why taking your statin matters

Anna Keller, 47 · 16 September 2026 · Shared with the patient, 16 September 2026, opened

Why this medicine matters

Your LDL cholesterol is 162 mg/dl. Together with your blood pressure and your father's heart attack at 58, this raises your risk of a heart attack or stroke in the coming years.

LDL builds up in the walls of your blood vessels over time. Lowering it is one of the best-proven ways to protect your heart, and the benefit grows the longer you take the tablet.

The plan

You start atorvastatin 20 mg in the evening. This is a different molecule from the simvastatin you tried in 2024, and we expect your LDL to fall by about a third within eight weeks.

The target we are aiming for is below 100 mg/dl. If you are there and tolerating the tablet, nothing changes. If not, we can raise the dose or add a second medicine.

What to watch for

  • Muscle pain that is new or unusualIn 2024 you had aches on simvastatin. Note when it started and where, and tell us. We check a blood value and adjust. Do not stop on your own unless the pain is severe.
  • Grapefruit in large amountsIt raises the level of atorvastatin in your blood. A glass now and then is fine.

Next

  • Week of 9 Nov 2026Blood test: cholesterol, liver and muscle values
  • 16 Nov 2026, 10:30Follow-up with Dr. Weber

Sources

Eur Heart J 2020Lancet 2016

Written from the visit, the chart and two guideline sources, in plain language, with the physician's own instruction about the muscle symptoms of 2024. Shared under her name.

Visit note

The visit in your structure: reason, findings, assessment, plan.

Open alone
Visit note

Visit of 16 September 2026

Anna Keller, 47 · 16 September 2026 · Signed, in the chart

Reason
Blood pressure control, lipids, decision on statin therapy.
Findings
BP 142/88, HR 72, BMI 29.1. Lab 12 September: LDL 162 mg/dl, HbA1c 5.9 %, ALT 41 U/l. Father: myocardial infarction at 58. Simvastatin stopped 2024 for myalgia.
Assessment
Hypertension not at target under ramipril 5 mg; primary prevention with high LDL and premature family history; prediabetes; mild steatosis.
Plan
Atorvastatin 20 mg started, CK and ALT after six weeks; lipoprotein(a) once; ramipril to 10 mg; home blood pressure for four weeks; follow-up in three months.

Written from the recording of the visit and what was open on screen, in the practice's structure. Signed by Dr. med. Sarah Weber; every sentence points to its passage in the conversation.

Referral letter

The letter to a colleague, written from the chart, with the question stated.

Open alone
Referral letter

Referral: coronary artery calcium scoring

Anna Keller, 47 · 16 September 2026 · Draft, for your signature

Draft. It carries your name after you sign it.
To
Cardiology practice, Hamburg
Subject
Referral of Mrs Anna Keller, born 1979, for coronary artery calcium scoring

Dear colleagues,

I am referring Mrs Keller, 47, for a coronary artery calcium score to refine her cardiovascular risk before committing to long-term lipid-lowering therapy.

Findings: arterial hypertension since 2023 (ramipril, increased to 10 mg today; home mean 136/86 mmHg), LDL cholesterol 162 mg/dl, non-HDL 186 mg/dl, HbA1c 5.9 %, BMI 27.4, former smoker (10 pack-years, stopped 2019), mild hepatic steatosis on ultrasound (May 2026), eGFR 92 ml/min. Family history: father with myocardial infarction at 58. Lipoprotein(a) is ordered with the next blood draw. SCORE2 is about 3 %, low to moderate for her age; the family history and the LDL level are the reasons for the question.

Simvastatin 20 mg was stopped in March 2024 for myalgia with a CK of 210 U/l; atorvastatin 20 mg is started today as a rechallenge. Current medication: ramipril 10 mg, atorvastatin 20 mg, sertraline 50 mg, vitamin D3 1,000 IU.

The 2021 ESC prevention guideline lists coronary artery calcium scoring as a risk modifier that may be considered in people at low-to-moderate risk. I would be grateful for the score and your assessment of whether the result changes the treatment intensity.

With kind regards,

Dr. med. Sarah Weber

Internal medicine and general practice, Hamburg

Drafted from the chart and today's visit. A draft: it carries the physician's name only after signing.

Patient question

A question from the patient app, with the plan it touches, what the patient already heard, and a reply to approve.

Open alone
Patient question

Muscle aches on atorvastatin, since yesterday

Anna Keller, 47 · 16 September 2026, 13:22 · Draft, for your signature

Draft. It carries your name after you sign it.

How the question was formed

The patient · 13:14

I have had muscle aches since yesterday. Should I stop the atorvastatin?

Mosaic

I cannot answer that one. Your plan asks you to report new muscle pain and to keep taking the tablet unless the pain is severe, so telling us is exactly right. Before I send this to Dr. Weber, is this the question you want to ask?

Mosaic proposed the wording; the patient confirmed it unchanged at 13:22.
The patient · 13:22

Yes. I have had muscle aches in both thighs since yesterday. Should I stop the atorvastatin, or keep taking it?

Confirmed and sent. Nothing else from her record went with it.

What you need to answer it

Her plan
Atorvastatin 20 mg every evening, started 16 September 2026. Signed by you. It asks her to note new or unusual muscle pain and tell the practice, and to keep taking the tablet unless the pain is severe.
From the chart
Simvastatin 20 mg stopped March 2024 for myalgia, CK 210 U/l. CK before this start 96 U/l, 8 May 2026. None since. eGFR 92.
Already said
That reporting it was right, and that the 2024 myalgia is in her chart. Nothing about stopping, halving or switching.

Draft reply, written from her plan and her chart

Your reply

Thank you for telling me straight away, that is exactly right. Please keep taking the tablet for now unless the pain is severe or you feel unwell.

I would like a blood test this week to check the muscle enzyme, so we know whether this is the tablet. Come by the practice for a blood draw, no appointment needed, the laboratory is open from 8 to 11.

If the pain gets worse, or you notice dark urine or weakness, stop the tablet and call us the same day.

Nothing is sent until you approve it. Edit any sentence; the reply goes out under your name, not Mosaic's.

The patient agreed the wording of her question with Mosaic before it was sent. The reply is a draft from her plan and her chart; you are its author once you approve it.

Measured at home

What the patient measured between visits, as a series with its mean, against the target in her plan.

Open alone
Measured at home

Blood pressure at home, seven days

Anna Keller, 47 · 15 September 2026 · Signed, in the chart

Morning readings

1449 Sep
14810 Sep
14111 Sep
13912 Sep
14513 Sep
14214 Sep
14015 Sep

mmHg systolic · target below 130

What the week shows

  • Morning mean 143/91, evening mean 129/81A morning-dominant pattern under ramipril taken in the morning.
  • Highest single reading 148/92 on 10 SeptemberNo symptoms reported alongside it.
  • No reading came with chest pain, breathlessness or neurological symptomsMosaic asks that with every entry and escalates immediately if the answer changes.

What Mosaic did not do

  • It did not change anythingThe readings sit in the chart for the visit of 16 November. A dose is a decision, not a measurement.

Entered by the patient twice a day for seven days, on the schedule her plan asked for. Nothing was inferred; the mean is the arithmetic mean of the fourteen readings.

Symptom trend

How symptoms moved since treatment started, and which reported event needs a look before the next visit.

Open alone
Symptom trend

Symptoms since starting transdermal estradiol

Petra S., 51 · 30 October 2026 · Signed, in the chart

Since 18 September

  • Hot flushesMeasured as her own count each evening, asked three times a week.9 → 4 a day
  • Night-time waking3 → 1 a night
  • Mood and concentrationHer own rating, no direction yet at six weeks.unchanged
  • Breast tendernessCommon in the first weeks and named in her take-home.from none to mild
  • SpottingFirst report. Under an unopposed interval it would matter; she takes progesterone, and the date is what the physician needs.12 October

Hot flushes a day

9wk 1
8wk 2
7wk 3
5wk 4
5wk 5
4wk 6

self-reported count

How the questions were asked

  • Three times a week, four questions, under a minuteThe schedule stops on its own after twelve weeks unless the physician extends it.
  • Every entry asks the safety question for this therapyMigraine with aura returning, leg swelling, chest pain. All answered no so far.

Collected in the patient app three times a week since 18 September. Counts are her own; the direction is the change between the first and the last two weeks.

Private service agreement

What a service outside the statutory catalogue costs, named before it happens, as German law requires.

Open alone
Private service agreement

Private service: lipoprotein(a), once

Anna Keller, 47 · 16 September 2026 · Shared with the patient, 16 September 2026

Why this one is not covered

Lipoprotein(a) is measured once in a lifetime and changes how your risk is calculated, which matters because your father had a heart attack at 58. The statutory catalogue does not list it for people without known cardiovascular disease, so it cannot be billed to your insurer.

Everything else from today, the visit, the blood pressure, the other blood values, the vaccination and the two prescriptions, is covered. Your app, the plan and the explanations cost you nothing: the practice pays for them.

What it costs

  • GOÄ 3730Lipoprotein(a), immunological determinationFactor 1.1518.63 €
  • GOÄ 250Blood drawFactor 1.154.67 €
  • Total, payable by you23.30 €

What this means

  • You decide. Declining changes nothing about your treatment today.
  • You sign before the blood is drawnGerman law requires a written agreement on a private service before it happens.
  • You get an invoice from the practice, not from your insurerSome private supplementary policies reimburse it; ask yours.

Prices from the German scale of fees for physicians (GOÄ), at the factor the practice applies. Required before a service outside the statutory catalogue, §18 of the federal agreement between physicians and statutory insurers.