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MediCaddie
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Clinical AI Assistant
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Recent Cases
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Raw Note
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Clinical Note
CHIEF COMPLAINT: Chest pain and shortness of breath x 2 days. HISTORY OF PRESENT ILLNESS: John Mitchell is a 68-year-old male with hypertension and type 2 diabetes presenting with pressure-like chest pain 6/10, radiating to the left arm, with associated dyspnea on exertion. PAST MEDICAL HISTORY: - Hypertension, essential (I10) - Type 2 Diabetes Mellitus, uncomplicated (E11.9) - Hyperlipidemia (E78.5) - Coronary Artery Disease, stable (I25.10) MEDICATIONS: Lisinopril 10mg, Metformin 500mg BID, Atorvastatin 40mg, Aspirin 81mg VITALS: BP 148/92 | HR 88 | O2 Sat 97% | Temp 98.6F ASSESSMENT AND PLAN: 1. Chest pain - rule out ACS; serial troponins, EKG monitoring 2. HTN - BP elevated; add HCTZ 12.5mg daily 3. Type 2 DM - HbA1c pending; continue Metformin 4. Hyperlipidemia - continue Atorvastatin
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EHR Data Retrieved
Epic MyChart • Athena Health • Last synced just now
Patient Demographics
Full Name
Sarah Johnson
Date of Birth
August 22, 1975 (Age 50)
MRN
A-28456789
Insurance
Aetna PPO — ID: AET-847291034
PCP
Dr. James Williams, MD
Allergies
Penicillin — Anaphylaxis
Sulfa Drugs — Rash
Current Medications
Levothyroxine 50 mcg tablet
Once daily on empty stomach
Omeprazole 20 mg capsule
Once daily before breakfast
Sertraline 50 mg tablet
Once daily
Active Diagnoses (ICD-10)
E03.9
Hypothyroidism, unspecified
2019
K21.0
GERD with esophagitis
2021
F41.1
Generalized anxiety disorder
2020
Most Recent Vitals — Jun 10, 2026
Blood Pressure
118
/76 mmHg
Heart Rate
72
bpm
Weight
147
lbs
BMI
23.7
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