Shoshana Haimovich | Nushito Health

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Active To-Do

✓

Urgent

📞 Family doctor call — ask all 7 questions

1. Acetaminophen dose for CKD (eGFR ~29) · 2. Injection type (not steroids — hyaluronic acid?) · 3. Home physio referral status · 4. Elastic bandage guidance · 5. Chest X-ray Tuesday — confirm indication (heavy phlegm Jan 2026) · 6. Amlodipine → Zanidip — refer to cardiologist? · 7. Kyphosis physio — exercises instead of brace

Mon 2026-07-28 · phone appointment

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Urgent — Do NOT cancel

🔬 Chest X-ray — attend as scheduled

Indication: heavy phlegm (ליחה רבה) January 2026. Separate from orthopedist's "no joint X-ray" logic. Context: Mitral Stenosis + heart failure + unconfirmed ureteral mass = legitimate pulmonary follow-up.

Tue 2026-07-29

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Critical med safety

💊 Eliquis dose — confirm she's on 2.5mg BID not 5mg BID

She meets BOTH criteria for dose reduction: age ≥80 ✓ + Creatinine ≥1.5 (1.70) ✓. If still on 5mg BID she is likely overdosed. Ask family doctor Monday.

Ask on Mon 07-28 call

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This week

🌡️ Vitamin D — reduce or pause dose

Level 141.2 nmol/L — above target (75–125 nmol/L for osteoporosis). Not yet toxic (>150), but dose should come down. Monitor calcium. Confirm with doctor Monday.

Labs: 2026-07-22

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This week

🦋 TSH 4.34 on Amiodarone → Endocrine review

Amiodarone (Procor) commonly causes amiodarone-induced hypothyroidism (AIH). TSH trending above normal. Needs endocrinology or at minimum thyroid panel (free T4). Flag to family doctor Monday.

Labs: 2026-07-22

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This week

⚡ Potassium 5.3 + ARB 240mg/day + CKD — reassess Valsartan dose

Combination of high-dose ARB (Valsartan 240mg/day) + CKD (eGFR ~29) risks dangerous hyperkalemia. Potassium 5.3 is already mildly elevated. Ask doctor to review. Do not reduce independently.

Labs: 2026-07-22

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Ongoing

🏃 Home physiotherapy referral — follow up status

Orthopedist wrote referral but skeptical she'll get it (national shortage). Ask family doctor Monday: alternative pathways? Supplemental insurance? Private?

Referral written: 2026-07-26

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Ongoing

💉 Joint injection — get specifics and referral

Orthopedist recommended injection (not steroids). Likely hyaluronic acid (viscosupplementation). Confirm type, who performs it, and whether a separate referral is needed.

From ortho visit: 2026-07-26

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Watch

❤️ Amlodipine → Zanidip (Lercanidipine) — cardiologist referral

Amlodipine 10mg causing chronic leg edema. Lercanidipine (Zanidip) is more vascular-selective, less edema. Do not switch without cardiologist sign-off given her AFib + mitral stenosis + complex med regimen.

Ongoing discussion

✓

Watch

🫀 Echo — current status of mitral stenosis?

Mitral stenosis on record since 1999. No recent echocardiogram on file. In the context of heart failure management + pulmonary symptoms (phlegm Jan 2026), a current echo would be informative. Ask family doctor for referral if >2 years since last.

Unknown last echo date

✓

Watch

🧪 AST 39 on Amiodarone — liver watch

Amiodarone hepatotoxicity risk. AST at upper limit. Trending needed — compare to prior liver panel. If trending up, cardiology needs to weigh risk/benefit of continuing amiodarone.

Labs: 2026-07-22

⚠ Clinical Alerts ▾

🔴 Critical — Med Safety

Eliquis Dose Likely Wrong

Age ≥80 + Creatinine 1.70 (≥1.5) → dose should be 2.5mg BID, not 5mg BID. Verify immediately. Overdose = bleeding risk on anticoagulation.

🔴 Critical — Renal + Cardiac

Hyperkalemia Risk: K⁺ 5.3 + ARB 240mg + CKD

High-dose Valsartan (160+80mg/day) raises potassium. CKD (eGFR ~29) reduces potassium excretion. K⁺ 5.3 is already elevated. Dangerous combination requires dose reassessment.

🟡 Warning — Endocrine

TSH 4.34 → Amiodarone-Induced Hypothyroidism

Amiodarone (Procor) commonly causes thyroid dysfunction. TSH above normal. Needs thyroid panel (free T4) and endocrine review before attributing to other causes.

🟡 Warning — Vitamin D

Vitamin D 141.2 nmol/L — Above Target

Target for osteoporosis: 75–125 nmol/L. At 141.2 she is above range (not yet toxic >150). Reduce or pause Vitamin D supplement. Monitor calcium.

🟡 Warning — Hepatic

AST 39 (Upper Limit) on Amiodarone

Amiodarone hepatotoxicity is a known risk. AST at upper limit. Compare to prior liver panels. Trending up = flag to cardiology for risk/benefit reassessment.

ℹ Oncology — Unresolved

Right Ureteral Mass 2cm — No Confirmed Malignancy

Identified 06/2025. Causing right hydronephrosis + CKD. No malignancy confirmed as of 07/2026. Admitted to oncology via DCIS pathway. Family chose monitoring/palliative frame.

ℹ Pulmonary — Active

Chest X-Ray Tuesday — Do Not Cancel

Indication: heavy phlegm January 2026. Context: mitral stenosis + heart failure + ureteral mass. The orthopedist's "no joint X-ray" logic does NOT apply here. Different study, different indication.

ℹ Renal

CKD Stage 3b–4 (eGFR ~29) — Stable Baseline

Creatinine 1.70 (07/2026). Chronically elevated 1.31–1.76 throughout 07/2025–07/2026. Likely chronic from obstructive nephropathy (ureteral mass). Stable, not acute — but serious. Affects drug dosing throughout.

💊 Current Medications ▾

Eliquis (Apixaban)

5mg BID ⚠️ — may need 2.5mg

Morning + Evening

Anticoagulation for AFib / TIA history

⚠ Dose reduction criteria met: age ≥80 + Creatinine ≥1.5. Verify with doctor.

Fusid (Furosemide)

20mg

Morning

Loop diuretic — heart failure / fluid overload / edema

Vasodip (Amlodipine)

10mg

Morning

Calcium channel blocker — hypertension

⚠ Causing chronic leg edema. Consider switch to Zanidip (lercanidipine) — needs cardiologist review first.

Valsartan (ARB)

160mg AM + 80mg PM = 240mg/day

Morning + Evening

ARB — hypertension

⚠ High dose + CKD + K⁺ 5.3 = hyperkalemia risk. Reassess dose.

Cadex (Doxazosin)

1mg

Noon

Alpha-1 blocker — hypertension. Note: also used for urinary retention — relevant given urological history.

Procor (Amiodarone)

200mg

Noon

Class III antiarrhythmic — AFib rhythm control

⚠ Monitor: TSH (hypothyroidism risk), AST/ALT (hepatotoxicity), pulmonary (toxicity possible).

Iron

Dose not specified

Afternoon

Anemia / iron supplementation (Hb 13.1 low-normal)

Vitamin D

Dose not specified

Morning

Bone health

⚠ Level 141.2 nmol/L — above target (75–125). Reduce or pause dose.

Acamol (Acetaminophen) — New

Dose TBD — ask doctor

As needed for pain

Analgesic for osteoarthritis knee pain. Safer than NSAIDs in CKD. But dose must be reduced for eGFR ~29 — likely 500mg q6–8h max. Confirm Monday.

🔬 Labs — 2026-07-22 ▾

CBC · Chemistry · Urine · Thyroid · Vitamins

CBC — Complete Blood Count

Test	Result	Normal Range	Status
WBC	8.4 K/ul	4.5–11.0	✅ Normal
Hemoglobin	13.1 g/dl	12.0–16.0	⚠ Low-normal
Hematocrit	39.6%	36–46%	✅ Normal
MCV	94.3 fL	80–100	✅ Normocytic
Platelets	342 K/ul	150–400	✅ Normal
Neutrophils	55.4% / 4.7K	40–70%	✅ Normal
Lymphocytes	33.2% / 2.8K	20–40%	✅ Normal
RDW	12.8%	11.5–14.5	✅ Normal

CBC essentially normal. No infection signal. Hb 13.1 low-normal — normocytic, likely anemia of chronic disease (not iron deficiency). Iron supplementation appropriate.

Chemistry + Lipids

Test	Result	Normal	Status
Glucose	89 mg/dL	70–100	✅ Normal
Creatinine	1.70 mg/dL	0.5–1.1 (F)	🔴 HIGH — CKD baseline
Urea / BUN	68.4 mg/dL	15–45	🔴 HIGH
eGFR (estimated)	~29 mL/min	>60	🔴 CKD Stage 3b–4
Potassium	5.30 mEq/L	3.5–5.0	⚠ Mildly elevated
Sodium	140.9 mEq/L	135–145	✅ Normal
Calcium	9.35 mg/dL	8.5–10.5	✅ Normal
Albumin	3.71 g/dL	3.5–5.0	⚠ Low-normal
AST (GOT)	39 U/L	10–40	⚠ Upper limit (amiodarone watch)
ALT (GPT)	26 U/L	7–40	✅ Normal
Alk Phosphatase	69 U/L	44–147	✅ Normal
Total Bilirubin	0.70 mg/dL	<1.2	✅ Normal
Cholesterol	213.9 mg/dL	<200	⚠ Borderline
LDL	127.4 mg/dL	<100	⚠ Elevated (palliative frame = values discussion)
HDL	63 mg/dL	>40	✅ Good
Triglycerides	119 mg/dL	<150	✅ Normal

⚠ Creatinine 1.70 is within her known chronic range (1.31–1.76 over the past year) — stable but serious. Primary driver: right ureteral obstruction + hydronephrosis since 06/2025.

Urine Microalbumin

Test	Result	Status
Microalbumin	34.00 mg/L	⚠ Flagged elevated
ACR	29.57 mg/g	⚠ Borderline (threshold: 30)

Thyroid & Vitamins

Test	Result	Status
TSH	4.340 mIU/L	⚠ Above normal (0.4–4.0) — amiodarone AIH
Vitamin D	141.2 nmol/L	⚠ Above target (75–125)
Vitamin B12	341 pmol/L	✅ Normal

📋 Medical History ▾

12/2025

DCIS — Ductal Carcinoma In Situ (Breast)

Non-invasive breast cancer. At 91, active surveillance is often appropriate. Current management decision on file: admitted to oncology dept via this pathway. No confirmed active treatment as of 07/2026.

06/2025

Right Ureteral Mass 2cm + Right Hydronephrosis

Obstructive uropathy — right kidney drainage blocked by 2cm ureteral lesion. Causing CKD (eGFR ~29). No confirmed malignancy as of 07/2026. Family has chosen monitoring/palliative frame. No stenting/nephrostomy pursued.

31/08/2020

Atrial Cardioversion

Electrical cardioversion for AFib rhythm control.

12/05/2020

Atrial Fibrillation (AFib) Diagnosis

Ongoing. On amiodarone (rhythm control) + Eliquis (anticoagulation). TIA history reinforces need for anticoagulation.

2020

Hypercholesterolemia

LDL 127 on current labs. In palliative frame at 91 — treatment is a values discussion, not standard protocol.

24/05/2018

TIA — Transient Ischemic Attack

Stroke precursor. Resolved without permanent deficit. Key driver for maintaining anticoagulation with Eliquis.

2008

Essential Hypertension

On complex 4-drug regimen: Amlodipine + Valsartan (x2) + Doxazosin. High total ARB dose needs reassessment in context of CKD.

2005

Dyspepsia + Fatty Liver

Background GI history. Cholecystectomy (1977) → bile acid malabsorption possible. AST watch relevant in context of amiodarone.

1999

Mitral Stenosis

Narrowing of the mitral valve — can cause pulmonary congestion, reduced cardiac output. Heavy phlegm (Jan 2026) may be related. Current echo status unknown. Drives AFib management.

1977

Cholecystectomy (Gallbladder Removal)

Historical. Risk of bile acid malabsorption → GI symptoms possible.

📅 Recent Events ▾

2026-07-26 Orthopedics

Orthopedist Visit — Knee/Hip Pain

Diagnosis: Cartilage erosion (osteoarthritis — joint wear). Treatment plan:

Injection — not steroids (likely hyaluronic acid; type/referral TBC)
Elastic bandage — specific type, size, and how-to TBC with family doctor
Acamol (acetaminophen) for pain — dose must be confirmed for CKD
No back brace for kyphosis — correct reasoning: brace weakens paraspinal muscles; kyphosis worsens when removed
Home physiotherapy referral written — skeptical approval; national shortage
No joint X-ray referral given — "we know what we'll see: no cartilage. No need for unnecessary radiation" (NOTE: this logic does NOT apply to the chest X-ray)

2026-07-22 Labs

Full Blood Panel — CBC + Chemistry + Thyroid + Vitamins + Urine

Key findings: CKD stable (Cr 1.70 within known range). Potassium 5.3 — mildly elevated, hyperkalemia risk on high-dose ARB. TSH 4.34 — amiodarone-induced hypothyroidism watch. Vitamin D 141.2 — above target, reduce dose. AST 39 — upper limit, amiodarone liver watch. CBC essentially normal. Hb 13.1 low-normal (normocytic, anemia of chronic disease).

2026-07-22 Oncology

Oncology Department Access Confirmed

Admitted to oncology department via DCIS (breast) pathway. No confirmed malignancy diagnosis for ureteral mass as of this date. Family managing under monitoring/palliative frame. No active cancer treatment in progress.

2026-07-19 Nushito Onboarded

Nushito Joins Shoshana Health Group

Nushito AI concierge internist begins active monitoring. Patient chart opened. Mira (Bez's sister, co-caregiver) confirmed as primary contact. Patient preference confirmed: monitoring + palliative care only. No procedures.

2026-01 (approx) Pulmonary

Heavy Phlegm / Productive Cough Episode

Significant expectoration reported. Chest X-ray ordered as follow-up. Given mitral stenosis + heart failure (Furosemide), this likely reflects pulmonary congestion — but malignancy and infection must be excluded. X-ray scheduled for 2026-07-29. Do not cancel.

👨‍⚕️ Care Network ▾

Person	Role	Notes
Mira Haimovic	Daughter · Primary on-site caregiver	Co-collaborator with Nushito. Attends appointments. Israel.
Bez Ambar	Son · Remote oversight (US)	Orchestrates medical strategy via Nushito.
Family Doctor	Primary care physician	Phone appointment 2026-07-28. 7 questions ready.
Orthopedist	Musculoskeletal	Seen 2026-07-26. Wrote physio referral. Injection pending.
Oncology Dept	Oncology	Admitted via DCIS pathway. Monitoring frame only.
Nushito 🩺	AI Concierge Internist	Monitoring, clinical analysis, question prep. Not a prescriber.