🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-18 06:15:38

Transcript

[00:00 → 00:08] Hi Vipa. How can I help you? I am not well mentally. What happened to you? I am feeling
[00:08 → 00:15] a lot of stress. Okay. I am Dr. Anujar specialized in psychology. So tell me your most symptoms
[00:15 → 00:21] right. So how long you are feeling your stress? Almost like one month. One month. And what
[00:21 → 00:26] is the reason of stress? I think work, environment and conditions. Yeah. You have seen your blood
[00:26 → 00:34] pressure is also on a higher side. How is your appetite? Yeah. My appetite is okay. Okay
[00:34 → 00:41] tight. And are you taking adequate fluid? No. Are you in any medication? No. Are you drinking?
[00:41 → 00:48] Some days? A smoking? Yeah. Any nausea feeling? Some days. I feel guilty when I am very
[00:48 → 00:55] cold and anxious. And how was your mental cycles? They delayed. They delayed? Are you pregnant?
[00:55 → 01:02] No. No. Okay. So I will recommend some tests for you and after the test we put you on some
[01:02 → 01:08] medication. Okay. But before that you need to do some workout and need to be happy with your husband.

Clinical Notes

Subjective

  • Patient: Vipa.

  • Primary Concern: Feeling a lot of stress for about one month due to work, environment, and conditions.

  • Symptoms:

    • High stress levels.
    • Guilt and anxiety.
    • Some days of nausea.
    • Delayed menstrual cycles.

  • Medical History:

    • Denies current medications.
    • Reports smoking.

Objective

  • Physical Examination:

    • Blood pressure noted to be on the higher side.
    • Patient reports normal appetite.
    • Inadequate fluid intake.
    • Denies current medications except for smoking.

  • Mental Status Examination:

    • Expresses feelings of guilt and anxiety.
    • Reports delayed menstrual cycles.

Assessment

  1. Anxiety and Stress: Present for about one month, likely related to work and environmental factors.
  2. Possible Nausea: Occasional episodes reported.
  3. Menstrual Irregularities: Delayed menstrual cycles noted.

Plan

  1. Diagnostics:

    • Recommend tests to further evaluate the patient's condition.

  2. Medication:

    • Propose starting medication after test results.

  3. Lifestyle Modifications:

    • Encourage adequate fluid intake.
    • Suggest exercise regimen to manage stress.

  4. Smoking Cessation:

    • Discuss the importance of quitting smoking for overall health.

  5. Follow-Up:

    • Schedule a follow-up to discuss test results and treatment options.
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