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Electronic Medical Record
Ananya Sharma · MRN-284019 · Encounter #EN-77201 · Dr. Rajesh Menon
AI COPILOT · CLINICAL COPILOT — DRAFT
Based on today's vitals (BP 128/82, HR 78, SpO₂ 97%) and lab values (Troponin 0.04, LDL 142), the patient is stable post-PCI. AI suggests continuing dual antiplatelet therapy, adding high-dose statin, and scheduling stress echo in 6 weeks. Watch for signs of restenosis.
S — Subjective
Patient reports mild chest discomfort during rest, rated 3/10. No radiation to arm. Denies shortness of breath. Compliant with medications. Reports improved appetite since surgery.
O — Objective
BP 128/82, HR 78, RR 16, Temp 98.6°F, SpO₂ 97% on room air. Alert & oriented ×3. Heart RRR, no murmurs. Chest clear bilaterally. Surgical site clean and dry.
A — Assessment
1. S/P PCI with drug-eluting stent to LAD — day 2, stable
2. Hypertension — controlled on current regimen
3. Type 2 DM — HbA1c 7.2, needs optimization
4. Post-op pain — well controlled
P — Plan
• Continue Aspirin 75mg + Clopidogrel 75mg
• Atorvastatin increased to 40mg HS
• Metformin 500mg BD
• Repeat ECG at 08:00
• Cardiac rehab consult
• Anticipate discharge in 3-4 days
Current Prescription
| Medication | Dose | Frequency | Duration | Notes |
|---|---|---|---|---|
| Aspirin | 75 mg | OD (morning) | Life-long | After food |
| Clopidogrel | 75 mg | OD | 6 months | Post-PCI |
| Atorvastatin | 40 mg | HS | Life-long | Bedtime |
| Metoprolol | 25 mg | BD | 3 months | BP monitoring |
| Metformin | 500 mg | BD | Life-long | With meals |