Robert Anderson
Key Diagnoses
Vital Signs
Allergies
AI Insights
Updated 2 hours agoCritical: Blood Pressure Trend
Consistently elevated readings over last 3 visits. Consider medication adjustment.
Warning: Vitamin D Deficiency
Recent lab shows low levels (18 ng/mL). Supplementation recommended.
Info: Medication Adherence
Patient reports missing Metformin doses 2-3 times weekly. Consider patient education.
Current Symptoms
Reported on Jun 24, 2023Chest Discomfort
Intermittent pressure-like pain, primarily when walking upstairs.
Fatigue
Progressive worsening over 3 weeks, affecting daily activities.
Frequent Urination
Nocturnal urination (2-3 times nightly). Consistent with diabetes.
Mild Headaches
Occurs mid-afternoon, resolves with rest. Possibly tension-related.
Body Health Map
Selected Health Issue
ECG shows minor ST segment abnormalities. Stress test scheduled. Recent cholesterol levels indicate increased risk.
Current Medications
Metformin
1000mg, Twice daily with meals
Lisinopril
20mg, Once daily in the morning
Atorvastatin
40mg, Once daily at bedtime
Recent Lab Results
HbA1c
Jun 15, 2023
Total Cholesterol
Jun 15, 2023
LDL Cholesterol
Jun 15, 2023
Vitamin D
Jun 15, 2023
Interactive Human Body Analysis
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Health Indicators
Critical Attention
Immediate review required
Warning
Monitor closely
Information
Notable findings
Normal
Within healthy parameters
System Health Summary
Interactive 3D model. Click on highlighted areas to see detailed information.
Selected Organ: Heart
CriticalFindings Summary
Stress ECG indicates possible coronary artery disease. ST depression observed during peak exercise. Echocardiogram shows mild left ventricular hypertrophy.
Relevant Test Results
Historical Data
AI Health Insights
High Risk Assessment: Patient's symptoms, history of hypertension, and ECG changes suggest elevated risk for coronary artery disease. Recommend cardiology referral within 1-2 weeks.
Health Timeline
Jan 5
Hospitalization
Feb 12
Cardiology Consult
Mar 20
Stress Test
Apr 8
Follow-up Visit
Jun 24
Current Visit
Current Visit (Jun 24, 2023)
Patient reports occasional chest discomfort and increased fatigue. ECG shows minor abnormalities, laboratory tests indicate elevated cholesterol levels. Plan includes statin dosage adjustment and cardiac referral.
Medical History
Complete chronological patient health record
Timeline View
| Date | Type | Description | Provider | Status | Action |
|---|---|---|---|---|---|
|
Jun 24, 2023
09:15 AM
|
Office Visit |
Follow-up for hypertension and diabetes management
Current visit
|
Dr. Sarah Johnson
Cardiology
|
Completed | View |
|
Apr 8, 2023
10:30 AM
|
Follow-up |
Follow-up after stress test, medication adjustment
|
Dr. Sarah Johnson
Cardiology
|
Completed | View |
|
Mar 20, 2023
2:15 PM
|
Diagnostic |
Exercise Stress Test - Abnormal findings
ST depression during peak exercise
|
Dr. Michael Chen
Cardiology
|
Completed | View |
|
Feb 12, 2023
1:45 PM
|
Consultation |
Cardiology consultation - Hypertension management
Referred by Dr. Emily Parker
|
Dr. Sarah Johnson
Cardiology
|
Completed | View |
|
Jan 5, 2023
3:20 AM
|
Hospitalization |
Admitted for chest pain and elevated blood pressure
Cardiac enzymes negative, Troponin normal
|
Dr. James Williams
Emergency Medicine
|
Discharged | View |
|
Nov 12, 2022
10:00 AM
|
Annual Exam |
Annual physical examination
Initial diagnosis of hypertension
|
Dr. Emily Parker
Primary Care
|
Completed | View |
Diagnoses History
Type 2 Diabetes
Diagnosed: Mar 15, 2019
Latest HbA1c: 7.8% (Jun 15, 2023)
Treatment: Metformin 1000mg BID
Hypertension
Diagnosed: Nov 12, 2022
Latest BP: 145/92 mmHg (Jun 24, 2023)
Treatment: Lisinopril 20mg daily
Hyperlipidemia
Diagnosed: Aug 3, 2021
Latest Total Chol: 245 mg/dL (Jun 15, 2023)
Treatment: Atorvastatin 40mg daily
Vitamin D Deficiency
Diagnosed: Jun 15, 2023
Latest Level: 18 ng/mL (Jun 15, 2023)
Treatment: Vitamin D 50,000 IU weekly
Allergic Rhinitis
Diagnosed: May 12, 2020
Seasonal - Spring/Summer
Treatment: Loratadine 10mg PRN
Community Acquired Pneumonia
Diagnosed: Dec 5, 2021
Resolved: Jan 15, 2022
Treatment: Amoxicillin-Clavulanate (completed)
Family Medical History
| Relation | Medical Conditions | Age at Diagnosis | Status |
|---|---|---|---|
|
Father
|
Coronary Artery Disease, Type 2 Diabetes
|
52 years, 48 years
|
Deceased at 68 (MI)
|
|
Mother
|
Hypertension, Breast Cancer
|
60 years, 65 years
|
Living, 78 years
|
|
Brother
|
Type 2 Diabetes, Hyperlipidemia
|
50 years, 52 years
|
Living, 58 years
|
|
Paternal Grandfather
|
Stroke, Coronary Artery Disease
|
65 years, 60 years
|
Deceased at 72 (Stroke)
|
AI-Generated Family Risk Assessment
Patient has significant family history of coronary artery disease, type 2 diabetes, and hypertension. These factors increase the patient's personal risk.
Recommended: Consider more aggressive preventive measures and screening protocols for cardiovascular disease.
Laboratory Reports
View and analyze all diagnostic test results
AI Lab Analysis Summary
Recent tests show concerning trends in lipid panel and blood glucose. Consider reviewing cardiology and endocrinology management plans. Vitamin D deficiency detected.
Comprehensive Metabolic Panel
AbnormalJun 15, 2023 • Dr. Sarah Johnson
Lipid Panel
CriticalJun 15, 2023 • Dr. Sarah Johnson
Hemoglobin A1c
AbnormalJun 15, 2023 • Dr. Sarah Johnson
Vitamin D
AbnormalJun 15, 2023 • Dr. Sarah Johnson
Stress ECG
AbnormalMar 20, 2023 • Dr. Michael Chen
ST depression during peak exercise. Possible coronary artery disease.
Echocardiogram
AbnormalMar 22, 2023 • Dr. Michael Chen
Mild left ventricular hypertrophy. Ejection fraction 55%.
Lipid Panel
Jun 15, 2023 • Dr. Sarah Johnson
Detailed Results
| Test | Result | Reference Range | Status | Trend |
|---|---|---|---|---|
| Total Cholesterol | 245 mg/dL | < 200 mg/dL | High | |
| LDL Cholesterol | 162 mg/dL | < 100 mg/dL | High | |
| HDL Cholesterol | 38 mg/dL | > 40 mg/dL | Low | |
| Triglycerides | 195 mg/dL | < 150 mg/dL | High | |
| Total Cholesterol/HDL Ratio | 6.4 | < 5.0 | High |
Historical Trend
AI Analysis
Critical: Elevated Cardiovascular Risk
Patient's lipid profile indicates high cardiovascular disease risk. LDL is significantly elevated despite statin therapy.
Recommended Actions
- Consider increasing atorvastatin dosage or adding ezetimibe
- Comprehensive lifestyle modification program
- Repeat lipid panel in 6 weeks to assess response
- Cardiology consult recommended if no improvement
Provider Notes
Patient with poorly controlled hyperlipidemia despite statin therapy. Discussed diet modification and exercise importance. Will increase atorvastatin to 80mg daily.
Imaging Studies
Chest X-Ray
Feb 12, 2023
Normal cardiac silhouette. No active disease.
Echocardiogram
Mar 22, 2023
LV hypertrophy. EF 55%. Diastolic dysfunction.
Abdominal Ultrasound
Dec 5, 2022
Mild hepatic steatosis. Normal gallbladder.
Stress ECG
Mar 20, 2023
ST depression at peak exercise. Possible CAD.
Current Medications
Manage and track patient's prescription medications
AI Medication Analysis
Patient shows poor adherence to Metformin (60%) which correlates with elevated HbA1c trends. Consider patient education or medication adjustment. Potential drug interaction detected between Atorvastatin and recently prescribed antibiotics.
Active Medications
Metformin
1000mg tablets, oral
1000mg twice daily with meals
Mar 15, 2022
Jun 10, 2023
60 tablets, 30 days
Type 2 Diabetes management
Take with food. Avoid alcohol. Monitor blood glucose regularly.
Lisinopril
20mg tablets, oral
20mg once daily in the morning
Nov 12, 2022
Jun 5, 2023
30 tablets, 30 days
Hypertension management
Take in the morning with or without food. Monitor blood pressure regularly.
Atorvastatin
40mg tablets, oral
40mg once daily at bedtime
Aug 3, 2021
May 28, 2023
30 tablets, 30 days
Hyperlipidemia management
Take at bedtime. Avoid grapefruit juice. Report muscle pain or weakness.
Vitamin D
50,000 IU capsules, oral
50,000 IU once weekly
Jun 24, 2023
Jun 26, 2023
12 capsules, 12 weeks
Vitamin D deficiency treatment
Take once weekly with food. Follow up with lab test after 12 weeks.
Medication Timeline
Discontinued Medications
| Medication | Dosage | Start Date | End Date | Reason |
|---|---|---|---|---|
|
Glimepiride
Oral tablets
|
2mg once daily | Mar 15, 2019 | Sep 20, 2021 | Switched to Metformin for better efficacy |
|
Amlodipine
Oral tablets
|
5mg once daily | Nov 12, 2021 | Feb 10, 2022 | Patient developed ankle edema; switched to Lisinopril |
|
Amoxicillin-Clavulanate
Oral tablets
|
875-125mg twice daily | Dec 5, 2021 | Dec 19, 2021 | Course completed for pneumonia |
Medication Interactions Analysis
Current Interactions
Moderate: Metformin + Atorvastatin
May increase risk of myopathy. Monitor for muscle pain/weakness.
Minor: Lisinopril + Metformin
May enhance hypoglycemic effect. Monitor blood glucose levels.
Contraindications & Precautions
Contraindication: NSAIDs
Avoid NSAIDs with Lisinopril due to risk of acute kidney injury. Patient has history of NSAID use.
Precaution: Alcohol
Limit alcohol consumption with Metformin and Atorvastatin due to increased risk of liver toxicity.
Dietary Restriction
Avoid grapefruit juice with Atorvastatin. May increase risk of side effects.
AI Insights & Recommendations
Smart analysis and clinical decision support
Critical Issues
3Immediate attention required for cardiovascular health, medication efficacy, and abnormal test results.
Warnings
5Monitor closely for medication adherence issues, vitamin deficiency, and recurring symptoms.
Information
7Notable findings including family history risks, social determinants, and lifestyle factors.
Positive Status
4Stable respiratory function, improved sleep patterns, and good response to current therapy.
Clinical Priorities
Cardiovascular Risk Management
Clinical Analysis
Patient has multiple cardiovascular risk factors (hypertension, hyperlipidemia, diabetes) with suboptimal control of each condition. LDL remains elevated at 162 mg/dL despite statin therapy. Blood pressure consistently above target at 145/92 mmHg.
AI Recommendation
- Consider increasing atorvastatin to 80mg daily or adding ezetimibe
- Evaluate for resistant hypertension; consider adding a thiazide diuretic
- Schedule cardiology consultation within 2 weeks
- Order stress echocardiogram to assess functional capacity
Diabetes Management
Clinical Analysis
HbA1c elevated at 7.8% (target <7.0%). Metformin adherence is suboptimal at 60%. Morning fasting glucose consistently elevated (142 mg/dL). Patient reports barriers to medication adherence including forgetfulness.
AI Recommendation
- Implement medication adherence program with reminders
- Consider once-daily diabetes medication as alternative
- Refer to diabetes education program for lifestyle optimization
- Schedule follow-up in 4 weeks to reassess control
Vitamin D Deficiency
Clinical Analysis
25-Hydroxyvitamin D level is 18 ng/mL (deficiency <20 ng/mL). Patient reports minimal sun exposure and few dietary sources of vitamin D. Associated with reported fatigue and muscle weakness.
AI Recommendation
- Continue vitamin D 50,000 IU weekly for 12 weeks
- Follow up with 25-hydroxyvitamin D level in 3 months
- Transition to maintenance dose of 1,000-2,000 IU daily
- Provide education on dietary sources of vitamin D
Health Trends Analysis
Blood Pressure
WorseningTrend shows consistent elevation with minimal response to current medication. Last three readings demonstrate upward trend.
Blood Glucose
FluctuatingPattern shows correlation between medication adherence and glucose control. Morning hyperglycemia noted most frequently.
Lipid Profile
Poor ControlLDL remains consistently elevated despite statin therapy. HDL shows gradual decline over past 6 months.
Weight
StableWeight stable between 208-212 lbs over past 6 months. BMI maintained at 32.4 (Obese Class I).
Risk Stratification
Cardiovascular Risk
Patient is at high risk for atherosclerotic cardiovascular disease events.
Risk Reduction Opportunity: Optimizing statin therapy and BP control could reduce 10-year risk to 9.7%.
Diabetes Complications Risk
Prevention Strategy: Improved glycemic control and regular screening would reduce complication risk by 35%.
Preventive Care Opportunities
-
Pneumococcal Vaccine
Due now (high risk patient)
-
Diabetic Eye Exam
Overdue by 4 months
-
Colonoscopy
Due in 3 months
-
Flu Vaccine
Current (received Nov 2022)
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