🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-06-12 22:49:53

Transcript

[00:00 → 00:04] Medio sumasakit po ang ulokonitong mga nakara ang haraw.
[00:04 → 00:08] Gaaanukadalas ang pananakit ng uluninyo.
[00:08 → 00:13] May papapobakayong nararamdaman, halus araw araw podok,
[00:13 → 00:16] minsan po ay may kasamang paggahilo at pag susuka.
[00:16 → 00:19] May iniinong baka yung gamot ngayon,
[00:19 → 00:22] o may allergy baka yung sanomang gamot.
[00:22 → 00:28] Wala po ako umregular nagamot at wala rin pung allergy sa pagga alam ko.
[00:28 → 00:32] Sigepo, kukunin ko muna ang inyong blood pressure.
[00:32 → 00:35] Pakeupulang pusan dali.
[00:35 → 00:37] Matas po ang blood pressure niyo.
[00:37 → 00:40] Maharing ito ang sanin ang madalas na pananakit ng ulok,
[00:40 → 00:45] nirerequest ko po na magpalaboratory test kayo para masiguro natin.
[00:45 → 00:49] Sigepo, kailang po ako pwedeng bumalik para sa resulta.
[00:49 → 00:53] Puede po kayong bumalik pagkatapos ng dalawang araw,
[00:53 → 00:55] dalin puni niyo ang resulta ng tests.
[00:55 → 01:00] Mibigyan ko rin kayo ng pansamantalang gamot para may psanang sakit.
[01:00 → 01:02] Maraming salamat po.
[01:02 → 01:04] Wala nganuman.
[01:04 → 01:08] Engat po kayo at huwag kalimutan uminom ng maraming tubik at magpahinga.
[01:08 → 01:09] Kung kailang.

Clinical Notes

Subjective

  • Patient: Complains of frequent headaches for the past few days, sometimes associated with dizziness and vomiting. Also experiencing palpitations and unsure if it's due to current medication or an allergic reaction. Denies regular medication use and any known allergies.

Objective

  • Blood Pressure: Elevated.

Assessment

  1. Headaches: Likely related to high blood pressure, requesting laboratory tests for further evaluation.

Plan

  1. Diagnostics:

  2. Order laboratory tests to investigate the cause of frequent headaches.

  3. Follow-Up:

  4. Advised to return after two days for test results.

  5. Medication:

  6. Prescribe temporary pain relief medication.

  7. General Advice:

  8. Encouraged to stay hydrated and get adequate rest.
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