Blog — Clinical Spanish

Spanish for dialysis nurses: the three-times-a-week patient who says “hoy no quiero venir,” the access site that the patient says is “igual de siempre” but looks different, and the dietary conversation that has to happen before the discharge that follows this appointment

Miguel Torres had been on hemodialysis three times a week for six years. He knew the unit’s nurses by name. He came in Monday, he came in Wednesday, he came in Friday. The week his daughter’s car broke down, he missed Wednesday. He called Thursday to say he was feeling fine and would come Friday instead. Friday he felt tired and told his wife the treatment was only three hours and he would be fine at home one more day. The nurse who called Friday afternoon heard “me siento bien” and “sí, voy el lunes.” She documented “patient declined, denies symptoms, verbalized understanding of importance.” Saturday morning Miguel weighed himself because his wife made him. He was 4.2 kilograms above his dry weight. He came to the unit Monday morning on a gurney. Three failure modes that recur in dialysis units every week—three times a week, with the most familiar patients on the floor— when familiarity becomes a reason to ask fewer questions.

Miguel Torres’s two missed sessions

Miguel had been on HD three times a week for six years when the car broke down. He was 54, ESRD from long-standing hypertension and type 2 diabetes, dry weight 78 kilograms. He was what the unit’s charge nurse called a “reliable patient”—which is a category that exists mostly to explain why the first missed session produced a phone call but not an assessment protocol.

The Wednesday call reached his voicemail. The Thursday call reached him. He said “me siento bien” and explained the car situation. The nurse asked if he had any swelling or trouble breathing. He said “no, estoy bien.” She asked if he could come in Friday. He said yes.

Friday he did not come in. When the nurse called, he said he was tired. She asked again about swelling and breathing. He said “pues, los pies sí están un poco hinchados”—and then said “pero eso me pasa a veces, no es nada.” The nurse documented the call and noted “bilateral ankle edema, patient minimizing, verbalized will attend Monday.” She did not ask his weight. She did not ask when his feet were last swollen. She did not ask about orthopnea. She did not ask how much he had been drinking.

“Pero eso me pasa a veces” from a patient on a three-times-a-week schedule who has just missed two sessions is not the same as “pero eso me pasa a veces” from a patient who came in yesterday. The context changes what the answer means. Without the context questions, the nurse cannot know what she is hearing.

The three-question assessment that was not asked on either call would have changed the picture. Fluid weight gain, orthopnea, and time since last session together describe a patient who is 4.2 kilograms above dry weight and has bilateral ankle edema and is telling you it is fine. That is not a patient who can wait until Monday.

Three failure modes for dialysis nursing in Spanish

1. The “hoy no quiero venir” call where “me siento bien” is not a clinical clearance

A patient on hemodialysis three times a week has a relatively narrow window between sessions before fluid and solute accumulation becomes clinically consequential. The window narrows further with each missed session. The failure mode in the missed-session call is not that the nurse is unkind or inattentive—it is that “me siento bien” is accepted as an answer to a clinical question it cannot actually answer.

“Me siento bien” tells you the patient’s subjective experience of this moment. It does not tell you how much fluid they are retaining, whether they have orthopnea, or whether their potassium is climbing. A patient with 3 kg of extra fluid and mild bilateral edema who has been sleeping slightly elevated because the bed feels more comfortable that way will tell you they feel fine. They are not lying. They have adapted to a compensated state and their reference point for “bien” has shifted with it.

The assessment that changes this call has three questions. None of them replace the clinical judgment about whether the patient needs to come in today, but all three of them give you actual information to make that judgment.

Weight:

“¿Se pesó esta mañana? ¿Cuánto pesó?”

(Did you weigh yourself this morning? How much did you weigh?)

If the patient does not weigh themselves at home, or if no scale is available:

“¿Sus tobillos se ven hinchados esta mañana? ¿Más que ayer? ¿Sus zapatos le aprietan más de lo normal?”

(Are your ankles swollen this morning? More than yesterday? Are your shoes tighter than usual?)

The shoe question is important because it is a concrete daily reference point that the patient already has. A patient who cannot describe their weight can describe whether the shoes that fit yesterday are tight this morning.

Breathing at rest:

“¿Puede respirar bien cuando está acostado? ¿O tiene que sentarse un poco para respirar mejor?”

(Can you breathe well when you’re lying down? Or do you need to sit up a little to breathe better?)

The orthopnea question is the most diagnostically useful of the three. The patient who has been sleeping with two pillows for the past two nights because the bed feels better that way is describing orthopnea without knowing the word. Ask specifically about position, not just about whether they can breathe. “¿Tiene que sentarse para respirar mejor?” produces a more accurate answer than “¿le cuesta trabajo respirar?” because it gives the patient a physical anchor.

Time since last session:

“¿Cuándo fue la última vez que vino al tratamiento?”

(When was the last time you came in for treatment?)

The answer to this question changes the interpretation of every other answer in the call. A patient who says “estoy bien” after missing one session is different from a patient who says “estoy bien” after missing two. The nurse who knows the last session date before calling can orient the conversation from the start; the nurse who does not know should ask, because the patient’s answer to “me siento bien” means something different depending on when the last treatment was.

If weight is elevated, if there is orthopnea, or if more than one session has been missed, the framing that conveys urgency without alarming enough to produce a hang-up:

“Su cuerpo no puede eliminar el líquido ni los minerales sin el tratamiento — y dos sesiones perdidas hacen que su cuerpo trabaje muy duro para mantenerse estable. Necesitamos verle hoy si es posible. ¿Hay alguien que pueda traerle?”

(Your body cannot remove the fluid or the minerals without the treatment — and two missed sessions make your body work very hard to stay stable. We need to see you today if possible. Is there someone who can bring you?)

“¿Hay alguien que pueda traerle?” converts the “I want to come but I can’t get there” barrier into something actionable. Many missed sessions for established dialysis patients are transportation barriers, not refusals. Naming the logistics question opens the door to solving the actual problem.

One phrase that does more harm than good in this call: “¿sabe que si no viene puede ser muy peligroso?” The patient who has been on dialysis for six years knows the stakes. Restating the danger makes them feel lectured, not helped, and is more likely to produce a defensive “ya lo sé, estoy bien” than a decision to come in. What they need is someone who asks the right questions and makes it logistically possible to come—not someone who reminds them of what they already know.

2. The access site the patient says is “igual de siempre” but looks different

The AV fistula assessment conversation has a failure mode that is nearly identical to the missed-session call failure mode: a familiar patient answers a general question with a general answer, and the general answer is accepted as clinical data. “¿Cómo está su fístula?” is not an assessment. It is a social question about a body part.

The patient who says “igual de siempre” is telling you their perception of the change relative to their own baseline. If their baseline includes mild warmth from a prior inflammation that resolved, or mild asymmetry that has been there for two years, then “igual” means “same as my individual baseline,” not “within normal clinical range.” The nurse who accepts “igual” as the answer has no information. The nurse who asks three specific questions has something to work with.

Thrill assessment:

“Cuando toca su fístula aquí — [demonstrate gently on the skin over the anastomosis site] — ¿siente todavía ese pequeño movimiento, como si algo vibrara por dentro?”

(When you touch your fistula here — do you still feel that small movement, like something vibrating inside?)

Most established dialysis patients know the thrill. They may not know the word “frémito” or “thrill,” but they know the sensation. The question that works is the one that describes what they have felt a thousand times—“como si algo vibrara por dentro”—so they can compare it to now. The patient who pauses and says “pues, a veces sí lo siento y a veces no” has just told you the thrill is intermittent. That is a clinical finding.

What to teach the patient to watch for at home:

“Si siente que ese movimiento — esa vibración — desaparece completamente, llámenos ese mismo día. Eso no puede esperar hasta la próxima sesión.”

(If you feel that movement — that vibration — disappears completely, call us that same day. That cannot wait until the next session.)

A patient who understands that the disappearance of the thrill is an emergency, not a “tell them at the next appointment” finding, is a first-line early warning system for access thrombosis. That understanding has to be taught explicitly, because the thrill disappearing does not feel like a crisis—it just feels like something is different.

Visual and skin changes:

“¿Nota que la piel sobre la fístula se ve diferente hoy — más roja, más caliente, o que la vena se ve más grande de lo que es normalmente?”

(Do you notice that the skin over your fistula looks different today — more red, warmer, or that the vein looks bigger than it normally does?)

The patient who sees their arm in the mirror every day has visual data that the nurse who sees them three times a week does not have in the same way. A developing pseudoaneurysm produces a bulge that grows gradually and may be most visible to the person who sees it every morning getting dressed. “Más grande de lo que es normalmente” is the language that gets the patient to compare to their own long-term baseline, not just to last session. The patient who says “pues, ha estado un poco más grande desde hace un mes pero no crecí que era importante” has just told you something has been changing for thirty days without a clinical evaluation.

Rest pain—steal syndrome screen:

“¿Le duele en el brazo de la fístula aunque no la estén usando — sobre todo cuando está en reposo, por la noche o en la mañana? ¿Siente los dedos fríos o entumecidos en ese brazo?”

(Does your fistula arm hurt even when it’s not being used — especially when you’re at rest, at night or in the morning? Do your fingers feel cold or numb in that arm?)

Ischemic steal syndrome presents as rest pain and paresthesia, not just access pain during cannulation. The patient who reports their arm is fine during dialysis but mentions it hurts at night when they mention it at all is describing a symptom pattern that warrants evaluation. “Aunque no la estén usando” separates the question from the cannulation experience and targets the rest-pain symptom directly.

The access site assessment is also the right moment for the graft or fistula care reminder:

“Recuerde no cargar cosas pesadas con ese brazo y no dormir sobre él. Si nota que algo presiona contra la fístula — una liga, el borde de la ropa, algo que le apriete — quíteselo de inmediato. Cualquier presión sostenida puede dañarla.”

(Remember not to carry heavy things with that arm and not to sleep on it. If you notice anything pressing against the fistula — a rubber band, a tight sleeve, anything that squeezes — remove it immediately. Any sustained pressure can damage it.)

See also the renal failure in Spanish post for the upstream diagnosis conversation and the language around explaining why dialysis is necessary in the first place.

3. The dietary and fluid restriction conversation that has to survive the gap between the clinic and the kitchen

The dietary restriction education for a dialysis patient covers, at minimum, fluid restriction, potassium, phosphorus, and sodium. In practice, it is often delivered as a printed handout in the last few minutes before discharge from a treatment session, when the patient is tired, ready to go home, and has been sitting in a chair for three hours. The failure mode is not that the nurse gave wrong information. It is that the information did not survive the gap between the clinic and the kitchen.

The gap exists for specific, predictable reasons. The handout describes restrictions in general categories — “limit potassium-rich foods” — without naming the specific foods in a Latin American diet that carry the most risk. A patient who avoids bananas because a nurse mentioned potassium may come in the next week with a potassium of 6.2 after eating a plate of frijoles de la olla with the family on Sunday. The banana was on the list. The frijoles were not mentioned.

Similarly, “limit fluids to 1 liter per day” fails when the patient does not know that caldo counts as a liquid. This is the most common single-item teaching failure in Spanish-speaking dialysis patients at many units, and it is entirely predictable and entirely preventable with one sentence.

See the discharge instructions in Spanish post for the general discharge education framework; below is the dialysis-specific content that must be added to it.

Fluid restriction—the caldo problem:

“Sus riñones ya no pueden eliminar el líquido extra del cuerpo — eso lo hace el tratamiento. Entre sesión y sesión, todo el líquido que toma se queda en su cuerpo hasta el próximo tratamiento. Por eso hay un límite.”

(Your kidneys can no longer remove extra fluid from the body — the treatment does that. Between sessions, all the fluid you drink stays in your body until the next treatment. That’s why there is a limit.)

Then, immediately:

“El caldo, la sopita, el cocido, el atole, el agua de frutas, los jugos — todo eso cuenta como líquido igual que el agua. Un tazón grande de caldo son como 250 a 300 mililitros. Si su límite es un litro al día, un tazón grande de caldo ya es la cuarta parte de su límite. Dos tazones son la mitad.”

(Broth, soup, stew, atole, fruit water, juices — all of those count as liquid just like water. A large bowl of broth is about 250 to 300 milliliters. If your limit is one liter per day, a large bowl of broth is already a quarter of your limit. Two bowls is half.)

The specific numbers matter. A patient who is told “el caldo cuenta” without a quantity anchor has no way to calibrate. A patient who knows that their afternoon caldo is 300 ml of a 1,000 ml daily limit can make decisions about what else they drink.

Ice also counts:

“El hielo también cuenta — cuando se derrite, es agua. Si chupa hielo para la sed, cúentelo.”

(Ice also counts — when it melts, it is water. If you suck on ice for thirst, count it.)

Thirst management without excess fluid intake:

“Para la sed, en lugar de tomar agua, puede enjuagarse la boca con agua fría sin tragarla, chupar un cubito de hielo pequeño, o comer una rodaja fina de limón. Eso ayuda con la sensación de sed sin agregar mucho líquido.”

(For thirst, instead of drinking water, you can rinse your mouth with cold water without swallowing it, suck on one small ice cube, or eat a thin slice of lime. That helps with the feeling of thirst without adding much liquid.)

Potassium—specific to what they eat:

“Los alimentos con más potasio en la dieta típica son los frijoles, las papas — sobre todo el puré de papa y las papas hervidas — el plátano o banana, el aguacate, la papaya, el jitomate y la salsa de jitomate, y las frutas secas como las pasitas. No tiene que dejar de comerlos todos para siempre — pero sí necesita comer porciones pequeñas y no comer varios de estos el mismo día.”

(The foods with the most potassium in a typical diet are beans, potatoes — especially mashed potatoes and boiled potatoes — banana or plantain, avocado, papaya, tomato and tomato salsa, and dried fruits like raisins. You don’t have to stop eating all of them forever — but you do need to eat small portions and not eat several of them on the same day.)

For canned beans specifically, because this comes up in every unit with a predominantly Latin American patient population:

“Los frijoles de lata — si los enjuaga muy bien con agua del grifo antes de comerlos — tienen menos potasio que los frijoles frescos o de olla. Si va a comer frijoles, los de lata bien enjuagados son la opción más segura. Los frijoles de olla tienen mucho potasio porque el potasio se queda en el líquido donde se cocieron.”

(Canned beans — if you rinse them very well with tap water before eating — have less potassium than fresh or pot-cooked beans. If you’re going to eat beans, well-rinsed canned beans are the safer option. Pot-cooked beans have a lot of potassium because the potassium stays in the cooking liquid.)

Do not frame the frijoles conversation as “you can’t eat beans.” In many Latin American households, frijoles are a daily staple and a cultural touchstone. “No puede comer frijoles” produces resistance and, often, silent non-compliance. “Puede comer frijoles de lata bien enjuagados en porciones pequeñas” gives the patient a path. The path will be followed more often than the prohibition.

Phosphorus—dairy, sodas, and phosphate binders:

“La leche, el queso, el yogurt, y la crema tienen mucho fósforo. El fósforo alto en la sangre hace que el calcio salga de sus huesos y se deposite en sus vasos sanguíneos — eso pone rígidas sus arterias y hace que el corazón trabaje más duro. Una porción pequeña de lácteos al día está bien; más que eso, todos los días, daña su corazón con el tiempo.”

(Milk, cheese, yogurt, and cream have a lot of phosphorus. High phosphorus in the blood causes calcium to leave your bones and deposit in your blood vessels — that makes your arteries rigid and makes the heart work harder. A small portion of dairy per day is fine; more than that, every day, damages your heart over time.)

Cola sodas also carry phosphorus from additives:

“Los refrescos de cola — Coca, Pepsi — tienen fósforo extra que se absorbe muy rápido. Si toma refrescos, los refrescos claros — Sprite, agua mineral, agua con gas — tienen menos fósforo que los de cola.”

(Cola sodas — Coke, Pepsi — have extra phosphorus that absorbs very quickly. If you drink sodas, clear sodas — Sprite, mineral water, sparkling water — have less phosphorus than the colas.)

For phosphate binders, because this is where medication reconciliation most often breaks down in dialysis patients:

“Esta pastilla — [nombre del medicamento] — no es para el dolor ni para la presión. Es para que el fósforo de lo que come no llegue a su sangre. Funciona solo si la toma AL MISMO TIEMPO que empieza a comer — no antes, no después, sino con el primer bocado. Si se la toma tres horas después de comer, el fósforo ya fue absorbido y la pastilla no pudo hacer nada.”

(This pill — [medication name] — is not for pain or for blood pressure. It’s so the phosphorus from what you eat doesn’t reach your bloodstream. It only works if you take it AT THE SAME TIME you start eating — not before, not after, but with the first bite. If you take it three hours after eating, the phosphorus has already been absorbed and the pill couldn’t do anything.)

The timing instruction for phosphate binders is the most commonly misunderstood part of the dialysis medication regimen. Patients who take them as a separate daily pill rather than a mealtime supplement get little to no benefit. The “al mismo tiempo que empieza a comer” phrase is the one that changes compliance behavior.

Sodium and the hidden salt sources:

“La sal hace que su cuerpo retenga líquido — entre sesiones, eso se acumula y hace que su corazón trabaje extra. Lo más importante no es la sal que agrega en la mesa — es la sal que ya viene en los alimentos. Los condimentos como el caldo Maggi, el sazón, el consomé en polvo, las sopas de sobre — todos tienen mucha sal. Las salsas embotelladas, los frijoles de lata sin enjuagar, y los embutidos como el chorizo y la mortadela también tienen mucha sal. Cocinar con hierbas frescas — cilantro, epazote, ajo, cebolla — da sabor sin agregar líquidos ni sal.”

(Salt makes your body retain fluid — between sessions, that accumulates and makes your heart work extra hard. The most important thing is not the salt you add at the table — it’s the salt already in foods. Condiments like Maggi seasoning, sazon, powdered consomme, instant soup packets — all have a lot of salt. Bottled sauces, unrinsed canned beans, and processed meats like chorizo and mortadella also have a lot of salt. Cooking with fresh herbs — cilantro, epazote, garlic, onion — gives flavor without adding liquid or salt.)

The Maggi and sazón specificity matters. Many patients who understand that salt is bad have no idea that the condiments they have used for decades are among the highest-sodium items in their diet. A general warning about salt does not reach those items. A specific list does.

Weight monitoring at home: the tool every dialysis patient needs to use

The single most useful clinical intervention the dialysis nurse can make for a Spanish-speaking patient’s between-session management is not a food list. It is a reliable system for detecting fluid accumulation before it becomes an emergency. The food list helps manage inputs; daily weight monitoring catches the outputs and their trends. See the talking about weight in Spanish post for the general conversation framework; the dialysis-specific version is below.

First, confirm whether the patient has a scale:

“¿Tiene una báscula en casa? ¿La usa regularmente?”

(Do you have a scale at home? Do you use it regularly?)

If yes:

“Pésese todas las mañanas, siempre a la misma hora, antes de desayunar y después de ir al baño. Eso le da el número más exacto. Apúntelo si puede — en un papel en el baño o en el teléfono. Si sube más de [X] kilos sobre lo que pesó el día que terminó su último tratamiento, llámenos ese día — no espere a la próxima sesión.”

(Weigh yourself every morning, always at the same time, before eating breakfast and after using the bathroom. That gives you the most accurate number. Write it down if you can — on a paper in the bathroom or on your phone. If you go up more than [X] kilograms above what you weighed the day your last treatment ended, call us that day — don’t wait for the next session.)

If no scale is available:

“Si no tiene báscula, use sus zapatos como referencia. Póngase los mismos zapatos cada mañana. Si un día le aprietan más que el día anterior, o si sus tobillos se ven hinchados cuando se levanta — antes de estar de pie por mucho tiempo — eso es señal de que está reteniendo líquido. Llámenos ese mismo día.”

(If you don’t have a scale, use your shoes as a reference. Put on the same shoes every morning. If one day they feel tighter than the day before, or if your ankles look swollen when you get up — before you’ve been standing for a long time — that is a sign you are retaining fluid. Call us that same day.)

Emergency signs that require a call or visit today, not the next scheduled session:

“Si le cuesta trabajo respirar cuando está acostado, si tiene que sentarse para respirar mejor, si siente que el corazón late muy rápido o de manera irregular, o si se siente muy débil sin razón clara — eso es una urgencia. No espere a la sesión. Vaya a urgencias o llámenos inmediatamente.”

(If you have trouble breathing when you’re lying down, if you have to sit up to breathe better, if you feel your heart racing or beating irregularly, or if you feel very weak for no clear reason — that is an emergency. Don’t wait for the session. Go to the emergency department or call us immediately.)

The teach-back for the entire dietary and fluid education is not “¿entendió?” The word “entendí” confirms that the patient heard the instructions, not that they can apply them. The teach-back that reveals whether the education landed:

“¿Puede decirme qué va a cambiar en lo que come o toma esta semana?”

(Can you tell me what you are going to change about what you eat or drink this week?)

The patient who says “voy a tomar menos caldo” understood the caldo instruction. The patient who says “voy a evitar las frutas” understood a potassium warning but may still be eating frijoles de la olla four days a week. The patient who says “pues, lo mismo pero con cuidado” has not received the education in a way that produced a concrete behavioral change. Ask a second time:

“¿Hay algo específico que come o toma regularmente que sea mejor cambiar?”

(Is there something specific you eat or drink regularly that would be better to change?)

This second question produces the frijoles, the caldo, the Coca-Cola, the sazón. It is the question that surfaces what the patient is actually eating, not what they think they were warned about.

For the full set of phrases used across the dialysis patient encounter, visit the Spanish for dialysis nurses reference page. To practice the missed-session call and the access site assessment as a nurse in a roleplay scenario, the practice module has both.

The patient education framework used above draws on the broader patient education in Spanish approach for chronic disease management: mechanism first, specific to what the patient eats and does, teach-back targeting behavior change rather than comprehension, and avoiding the prohibition frame when a path is available. A patient who is given a path follows it more often than a patient who is given a prohibition. In six years of three-times-a-week dialysis, Miguel Torres had been given both. The prohibition he knew. The path was what he needed more of.

Frequently asked questions about Spanish for dialysis nurses

What Spanish phrases should I use when a dialysis patient says they don’t want to come in today?

Start with acknowledgment, then assess before you accept “me siento bien” as a clinical clearance. Acknowledgment: “Entiendo que hoy es difícil venir. ¿Puede contarme cómo se ha sentido?” (I understand today is hard. Can you tell me how you’ve been feeling?) Then three specific questions regardless of their answer: weight or ankle swelling, breathing when lying down, and time since last session. If more than one session has been missed: “Su cuerpo no puede eliminar el líquido ni los minerales sin el tratamiento — dos sesiones perdidas hacen que su cuerpo trabaje muy duro. Necesitamos verle hoy si es posible. ¿Hay alguien que pueda traerle?” The transportation question converts a refusal into a logistics problem, which is more often the real barrier.

How do I assess a dialysis patient’s AV fistula in Spanish?

Three questions beyond “¿cómo está su fístula?” (1) Thrill: “Cuando toca su fístula aquí, ¿siente todavía ese pequeño movimiento, como si algo vibrara por dentro?” (2) Visual changes: “¿Nota que la piel se ve diferente — más roja, más caliente, o la vena más grande de lo normal?” (3) Rest pain: “¿Le duele en ese brazo aunque no la estén usando — sobre todo en reposo o de noche?” Teach: “Si esa vibración desaparece completamente, llámenos ese mismo día — eso no puede esperar.”

How do I explain fluid restrictions in Spanish to a dialysis patient?

Start with the mechanism: “Sus riñones ya no pueden eliminar el líquido extra — eso lo hace el tratamiento. Todo el líquido que toma se queda en su cuerpo hasta la próxima sesión.” Then the caldo problem immediately: “El caldo, la sopita, el cocido, los jugos — todo eso cuenta igual que el agua. Un tazón grande de caldo son 250–300 ml.” Close with teach-back: “¿Me puede decir qué va a cambiar en lo que toma esta semana?”

What should I say to a Spanish-speaking dialysis patient about potassium and phosphorus restrictions?

Name the specific foods they eat. Potassium: frijoles (especially de la olla), papas hervidas y puré, plátano, aguacate, papaya, jitomate y salsa. Then the path: “Los frijoles de lata enjuagados con bastante agua tienen menos potasio — si va a comer frijoles, esos son la opción más segura.” Phosphorus: dairy + cola sodas. For phosphate binders: “Esta pastilla funciona solo si la toma al mismo tiempo que empieza a comer — con el primer bocado, no antes ni después.”

How do I teach a dialysis patient to monitor their weight at home in Spanish?

If they have a scale: “Pésese cada mañana a la misma hora, antes de desayunar y después del baño. Si sube más de [X] kilos sobre su peso del día que terminó el tratamiento, llámenos ese día.” If no scale: “Póngase los mismos zapatos cada mañana — si le aprietan más, o sus tobillos se ven hinchados al levantarse, llámenos ese día.” Emergency signs: orthopnea, irregular heartbeat, or sudden weakness without a clear reason — “no espere a la sesión, vaya a urgencias.”