Clinical Intelligence Report
Robert Chen
MRN 88214·DOB 1957-08-14·68y M·Encounter ED-4871
Confidence
94/100
127 records · 14 encounters
Chief Complaint
Chest pain, radiating to left arm, 2 hours
Vitals on Arrival
BP
162/94▲
HR
102▲
RR
22
SpO₂
94%▲
Temp
37.1°C
Pain
7/10
AI-GeneratedSynthesized from 127 records across 14 encounters · Compiled in 2.3s
Review required · Not a substitute for clinical judgment§ 01
Patient Snapshot
Longitudinal synthesis68-year-old male with established coronary artery disease (two-vessel stenting, October 2023), type 2 diabetes mellitus, and hypertension. Presents with retrosternal chest pain radiating to the left arm, onset 2 hours prior at rest. Most recent ED encounter 4 months prior for similar presentation — discharged after negative serial troponins.
§ 02
Clinical Impressions
Signals requiring physician attentionattention
Cardiovascular
Presentation pattern closely parallels the patient's October 2023 NSTEMI. Current vitals (BP 162/94, HR 102) combined with cardiovascular history warrant acute coronary syndrome workup per institutional protocol.
attention
Metabolic
HbA1c trajectory: 7.2 → 7.5 → 7.8 → 8.4% over 15 months. Diabetes control deteriorating; may warrant endocrinology involvement post-stabilization.
notable
Pharmacogenomic
CYP2C19 *1/*2 intermediate metabolizer status documented 2024. Current clopidogrel therapy may have reduced antiplatelet efficacy. Previously flagged by pharmacy; no regimen change on record.
notable
Renal
Serum creatinine drift: 1.1 → 1.4 mg/dL over 12 months (eGFR 58). Consider renal protection if contrast imaging required.
§ 03
Relevant History
| Coronary artery disease | RCA and LAD stents, Oct 2023 | 2023 |
| NSTEMI | 3-day admission, discharged on DAPT | 2023 |
| Type 2 diabetes mellitus | HbA1c 8.4% (↑ from 7.2%) | 2018 |
| Hypertension | Suboptimal control, escalating | 2015 |
| Hyperlipidemia | On atorvastatin 40mg | 2015 |
Allergies
Penicillin (rash, 1998)
§ 04
Active Medications
| Aspirin | 81 mg · daily | |
| Clopidogrel | 75 mg · daily | PGx: reduced efficacy |
| Atorvastatin | 40 mg · daily | |
| Metformin | 1000 mg · BID | |
| Lisinopril | 20 mg · daily |
§ 05
Longitudinal Biomarker Trends
Directional changes with clinical significanceHbA1c
Reference: < 7.0 %
8.4%
+17% from 7.2
Jan '25Jul '25Jan '26Apr '26
LDL-C
Reference: < 70 mg/dL
118mg/dL
+34% from 88
Jan '25Jul '25Jan '26
Creatinine
Reference: 0.7 – 1.3 mg/dL
1.4mg/dL
+27% from 1.1
Jan '25Jul '25Jan '26Apr '26
Systolic BP
Reference: < 130 mmHg
162mmHg
+17% from 138
Jan '25Jul '25Jan '26Today
§ 06
Prior Workups & Open Items
Three prior ED evaluations for chest pain in past 36 months. Standard workup consistently included 12-lead ECG, serial troponin (0/3/6h), chest radiograph, BMP, CBC. Most recent stress echocardiogram (February 2025) demonstrated inducible ischemia in LAD territory; cardiology follow-up recommended but not attended.
Unattended Follow-Up
◆Cardiology follow-up (scheduled March 2025, missed)
◆Diabetes education referral (open since November 2025)
§ 07
Data Provenance
Every claim traceable to sourceEHR: 14 encounters
Labs: 84 results
Imaging: 6 reports
PGx: 1 panel
Meds: Active list
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