🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-02 03:00:03

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Patient">Patient</strong>: I've been drinking a lot of water lately. I feel fairly fatigued, like I will drink around three big water bottles a day and drink them really fast. And because of that, I'm using the restroom a lot. I just feel really tired and I've been feeling this way since last Monday. It's to the point where I can't sit through class because I have to get up every like 20 minutes to use the restroom. I'm also feeling really tired. I don't have the energy to do any of my homework. My mouth is dry. It's like, no matter how much I try to stay hydrated, no amount of water can fix that.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Doctor">Doctor</strong>: Okay, well let's take a look at your blood sugar. That's the first thing that's probably causing you to feel this way. It seems like the nurse took your blood glucose levels and you were at 360, which for a normal patient is around 80 to 120, so you definitely have high blood sugar. Do you have history of diabetics or hypoglycemia in your family?</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Patient">Patient</strong>: My dad has type 2 diabetes, but other than that, I don't think anyone else in my family has diabetes.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Doctor">Doctor</strong>: Okay, well we're going to send you to an endocrinologist to get you prescribed insulin.</p></div></td></tr></tbody>

Clinical Notes

Patient Identifier: PATIENT_NAME Date of Visit: SESSION_DATE Time of Visit: [Time of Visit]

Presenting Complaint (CC): Excessive thirst and fatigue

History of Present Illness (HPI): PATIENT_NAME, a [age] year old [gender], presents with complaints of excessive thirst and fatigue. The patient reports drinking approximately three large bottles of water daily and experiencing frequent urination, needing to use the restroom every 20 minutes. The symptoms have persisted since last Monday. The patient also reports dry mouth and lack of energy, impacting their ability to complete homework.

Review of Systems: • Constitutional: Excessive thirst, fatigue, dry mouth • Genitourinary: Frequent urination

Physical Examination: • Not documented

Past Medical History: • None reported

Family History: • Father: Type 2 diabetes

Medications: • None reported

Allergies: • None reported

Investigations: • Blood glucose level: 360 mg/dL (normal range: 80-120 mg/dL)

Labwork: • None reported

Triage Information: • Vital signs: [Record vital signs if available] • Pain score: [Record pain score if available]

Resuscitation and Stabilization Measures: • None required

Time-Sensitive Interventions: • Referral to endocrinologist for insulin prescription

Consultations and Notifications: • Endocrinology consult recommended

Critical Findings: • Elevated blood glucose level

Disposition: • Referred to endocrinologist

Follow-up Recommendations: • Follow-up with endocrinologist for insulin management

Impression/Plan: 1. Hyperglycemia: • Plan: Monitor blood glucose levels. Endocrinology referral for insulin therapy.

Note: This report is based on the provided information. Further evaluation and management may be required based on the patient's clinical presentation and response to treatment.

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