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Clinca Luz
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MO
María Ortega 41 F
Cédula 001-1234567-8 · NSS 123456789 · HUMANO · DOB 03/15/1985
AI Assistant Overview Vitals & Measurements
Ambient Scribe — Listening
"...how long have you had the fever, has it been constant or...?"
4 findings ready
AI Patient Brief

41F, history of hypertension. Presenting with 3-day fever and headache. Vitals show critically elevated BP (165/105), tachycardia, and low SpO₂ — recommend immediate review. Active penicillin allergy conflicts with a current prescription. No new labs since Jun 9.

Generated from chart + today's vitals · Regenerate
Elevated Risk Severe allergy · Penicillin Medication conflict 3 vitals abnormal View all →
O Vitals & Measurements Synced from device · 2 min ago Record new →
Blood Pressure HIGH
165/105
mmHg · Stage 2
Heart Rate HIGH
112
bpm · Tachycardia
Temperature HIGH
38.9
°C · Fever
SpO₂ LOW
91
% · Below normal
Weight
65.0
kg · BMI 24.5
AI Draft Findings from this visit Tap ✓ to chart it — no typing needed
Subjective — headache, 3 days, worse in evenings
Assessment — possible UTI, recommend urinalysis
Plan — refill Losartan 100mg, once daily
Order suggested — CBC, urinalysis
Active Problems View all →
No active problems recorded
Recent Labs View all →
Hemoglobina 11 g/dl ↓ Low Jun 9
Fasting Glucose 62 mg/dl Normal Jun 9
Potasio (K) 3.9 mmol/l Normal Jun 6
Active Medications 7 View all →
Phenoxymethylpenicillin
100.0 mg · Once daily
Allergy conflict
Furosemide
200 mg · Once daily
Insulin aspart
100 IU · As needed
Losartan
100 mg · Once daily
Paracetamol
600 mg · As needed
Demographics
Date of Birth03/15/1985
SexFemale
DocumentCédula 001-1234567-8
Contact
Phone—
Email—
Insurance
ARS ProviderHUMANO
PlanMi Salud Royal
Prescription History
P-17812873125156/12/2026