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AI Clinical Decision Support

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Michael Thompson

58M • MRN: 257943 • Primary: Dr. Sarah Chen

Primary Diagnosis
Coronary Artery Disease (CAD)
Hypertension
Type 2 Diabetes
Current Medications
Metoprolol 50mg daily
Lisinopril 20mg daily
Atorvastatin 40mg daily
Metformin 1000mg BID
Recent Vitals
BP: 155/92 (04/15/2025)
HR: 78 bpm
A1C: 7.8% (03/22/2025)
LDL: 115 mg/dL (03/22/2025)

AI Clinical Analysis

Generated from 28 documents across 3 systems

Uncontrolled Hypertension

Patient's BP consistently elevated over past 3 visits (155/92, 148/88, 152/90) despite current anti-hypertensive regimen.

Confidence: 96%

Moderate Cardiovascular Risk

10-year ASCVD risk calculated at 15.2% based on most recent lipid panel and clinical factors. Stress test from 12/2024 showed moderate ischemia in LAD territory.

Confidence: 92%

Medication Adherence Concerns

Pharmacy records indicate irregular refill patterns for Lisinopril. Patient mentioned difficulty remembering evening medications in nursing notes from last two visits.

Confidence: 89%

Lifestyle Factors

Patient reports moderate daily exercise (30 min walking) but nutrition assessment indicates high sodium intake. Recent social work note mentions increased stress due to caregiver responsibilities.

Confidence: 85%

AI Treatment Recommendations

Based on current guidelines and similar patient outcomes

Treatment Priority: Blood Pressure Control

Based on current clinical status, improving blood pressure control should be the primary treatment focus.

Medication Adjustment

Add Amlodipine 5mg daily for improved BP control

92%

Recommendation confidence score

Clinical Rationale
  • Patient's BP remains above goal despite current therapy
  • Adding calcium channel blocker is in line with JNC 8 guidelines for resistant hypertension
  • Amlodipine has demonstrated efficacy in combination with ACE inhibitors and beta blockers
Evidence Base
  • ACCOMPLISH trial: demonstrated superior outcomes with ACEi/CCB combination
  • AHA/ACC Guidelines (2023): recommend CCB addition for uncontrolled hypertension
  • Similar patients (n=43) in your practice showed 15mmHg avg. reduction with this regimen
Low drug interaction risk Covered by patient's insurance Minimal adverse effects profile

Medication Adherence Support

Implement once-daily dosing regimen and enroll in medication reminder program

88%

Recommendation confidence score

Clinical Rationale
  • Pharmacy records indicate inconsistent refill patterns
  • Patient has reported difficulty with evening medication adherence
  • Simplifying regimen may improve compliance and clinical outcomes
Evidence Base
  • Meta-analysis (2024): once-daily dosing improves adherence by 22-28%
  • Digital reminder programs show 31% improvement in medication adherence
  • Patient personas similar to Mr. Thompson show preference for morning medication routines
No additional cost Mobile app available Caregiver can be included

Diagnostic Testing

Schedule echocardiogram to assess for LVH and cardiac function

84%

Recommendation confidence score

Clinical Rationale
  • Patient with long-standing hypertension at risk for LVH
  • Abnormal ECG from 02/2025 with possible left ventricular strain pattern
  • No echocardiogram performed in past 3 years
Evidence Base
  • ESC Guidelines (2023): recommend echo assessment for target organ damage in resistant hypertension
  • LVH presence would increase CV risk score by 1.5-fold
  • May influence medication selection (ARBs/ACEi preferred in LVH)
Covered by insurance Available at main campus Non-invasive

Alternative Approaches

Higher dose ACE inhibitor instead of adding CCB. Lower efficacy in this case (78% confidence).

Thiazide-like diuretic option. May cause electrolyte imbalances, higher monitoring needs.

For specialized evaluation and management. Consider if BP remains uncontrolled after medication adjustments.

Similar Patient Outcomes

Population analysis based on 43 similar cases

0 1 Month 2 Months 3 Months 0 50% 100% Blood Pressure Control Achievement CCB Addition ACEi Increase Thiazide

This analysis shows outcomes for patients with similar clinical profiles to Mr. Thompson. Patients who received the recommended CCB addition (blue) showed better BP control at 3 months compared to those who received increased ACEi dosing (green) or thiazide addition (orange).

All AI recommendations are derived from evidence-based guidelines and should be reviewed by a clinician before implementation.

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