MO
JR
María Ortega 41 F
Juan Reyes 34 M
RIGHT NOW
Blood pressure is critically high — 165/105 (Stage 2)
Tachycardia and fever also present. AI suggests reviewing hypertensive protocol before continuing the visit.
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. Active penicillin allergy conflicts with a current prescription. Recommend immediate review before continuing.
34M, routine quarterly follow-up. No new complaints. Vitals stable and within normal range across the last 5 visits. No active medication conflicts. No flags.
Blood Pressure
HIGH
165/105
▲ 22 mmHg
mmHg · Stage 2
Blood Pressure
NORMAL
118/76
— stable
mmHg · Normal
Heart Rate
HIGH
112
▲ 9 bpm
bpm · Tachycardia
Heart Rate
NORMAL
72
— stable
bpm · Normal
Temperature
HIGH
38.9
▲ 1.2°C
°C · Fever
Temperature
NORMAL
36.7
— stable
°C · Normal
SpO₂
LOW
91
▼ 5%
% · Below normal
SpO₂
NORMAL
98
— stable
% · Normal
Weight
NORMAL
65.0
— 0 kg
kg · BMI 24.5
Weight
NORMAL
78.2
— stable
kg · BMI 23.1
AI Draft
Findings from this visit
Swipe right to confirm, left to dismiss — or tap
Subjective — headache, 3 days, worse in evenings
Assessment — possible UTI, recommend urinalysis
Plan — refill Losartan 100mg, once daily
Order suggested — CBC, urinalysis
No findings drafted yet — keep talking, AI is listening and will surface anything worth charting.
Active Problems
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No active problems recorded
Phenoxymethylpenicillin
100.0 mg · Once daily
Furosemide
200 mg · Once daily
Insulin aspart
100 IU · As needed
Losartan
100 mg · Once daily
Paracetamol
600 mg · As needed
Potassium chloride
1213 mg · Once daily
Retinol
5 IU · Once daily
Multivitamin
1 tablet · Once daily
Omega-3
1000 mg · Once daily
Recent Labs
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Hemoglobina
11 g/dl
↓ Low
Jun 9
Fasting Glucose
62 mg/dl
Normal
Jun 9
Glucosa al azar
139 mg/dl
Normal
Jun 8
Potasio (K)
3.9 mmol/l
Normal
Jun 6
Eritrocitos
4.8 mg/dl
Normal
Jun 6
Fasting Glucose
88 mg/dl
Normal
Jun 2
Cholesterol (Total)
182 mg/dl
Normal
Jun 2
Visit summary ready to review
AI compiled a SOAP note from confirmed findings, vitals, and orders.
AI compiled a brief SOAP note — routine visit, no flags.
Demographics
Date of Birth03/15/1985
Date of Birth02/02/1992
SexFemale
SexMale
DocumentCédula 001-1234567-8
DocumentCédula 002-7654321-0
Contact
Phone—
Email—
Insurance
ARS ProviderHUMANO
ARS ProviderHumano
PlanMi Salud Royal
PlanEstándar
Prescription History
P-17812873125156/12/2026
No prescriptions on file