🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-05-08 10:19:49
Transcript
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Clinical Notes
Subjective
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Patient: Good morning, doctor.
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Primary Concern: I've been feeling very tired lately, and I've noticed some unexplained weight loss.
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Symptoms:
- Fatigue
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Unexplained weight loss
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Medical History:
- No significant past medical history mentioned
Objective
- Vitals:
- Blood pressure: 120/80 mmHg
- Heart rate: 72 bpm
- Temperature: 98.6°F
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Respiratory rate: 16 breaths per minute
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Physical Examination:
- General appearance: Patient appears tired
- No other specific physical exam findings mentioned
Assessment
- Fatigue: Present with unexplained weight loss, further investigation needed to determine the underlying cause.
Plan
- Laboratory Tests:
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Order complete blood count (CBC) and comprehensive metabolic panel (CMP) to assess for any underlying medical conditions.
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Follow-Up:
- Schedule a follow-up appointment to discuss the results of the laboratory tests and determine the next steps based on the findings.