🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-31 04:45:29

Transcript

[00:00 → 00:06] Hello, I am with Havaru, so hello doctor, my name is Amit and I am suffering from severe
[00:06 → 00:08] headache with abdominal pain.
[00:08 → 00:15] I am facing issue while I am urinating in the washroom where I am feeling heavier pain
[00:15 → 00:17] in my penis.
[00:17 → 00:20] So this is about my problem, I am Amit over to you doctor.

Clinical Notes

Subjective

  • Patient: Amit

  • Primary Concern: Severe headache with abdominal pain, experiencing pain while urinating and feeling heavier pain in the penis.

Objective

  • No relevant data.

Assessment

  1. Urinary Tract Infection (UTI): Suspected due to pain while urinating and penile pain.

  2. Headache: Requires further evaluation to determine the cause.

Plan

  1. Diagnostics:
  2. Conduct a urine analysis to confirm UTI.

  3. Evaluate the headache further to determine the underlying cause.

  4. Treatment:

  5. Prescribe antibiotics if UTI is confirmed.

  6. Provide pain relief medication for headache.

  7. Follow-Up:

  8. Schedule a follow-up appointment to assess the response to treatment and adjust management accordingly.
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